benigh prostatic hyperplasia
TRANSCRIPT
BENIGN PROSTATIC HYPERPLASIA
DR. FRANCISCO N. ESTANISLAO JR.
General Objectives:
1) To present a case of benign prostate hyperplasia
2) To discuss the cause, symptoms and guideline of treatment of the disease
Specific objective:
1) To present a combination drug therapy for the disease
Patient’s Profile:
•P.L , 66 y.o male•married, Filipino, Roman Catholic farmer, residing at Consolacion, Cebu
Chief complaint :• Dysuria
•hypertensive for(5) years as claimed
highest BP of 150/100; usual BP 120/70
•herbal medications
• non diabetic, non asthmatic.
•HFD : (+) HPN
•Non smoker ; Occasional alcoholic drinker
•No allergies to food and drugs
•No previous hospitalization
Past Medical History:
I month PTA – noted to have dribbling and decrease in stream upon urination with occasional urinary frequency. Condition just tolerated. Took herbal medications with some relief. No consults done.
History of Present Illness:
5 days PTA - complained of lumbar pain radiating to the hypogastric area associated with urinary frequency. No fever. No meds taken.
History Of Present Illness
4 days PTA - sought consult with AP and prescribed with Paracetamol+Ibuprofen 1 tab 3x a day, Co Amoxiclav 625 mg 1 tab 3x a day with good compliance which afforded some relief.
History of present illness
Morning PTA – persistence of symptoms with dysuria thus sought consult and subsequently
admitted
History of present illness
Physical examinationExamined pt. conscious, coherent, afebrile NIRD:
Bp – 110/70 HR – 89 RR – 21 Temp 36.8
Skin: senile turgor , no lesions
HEENT: anicteric sclerae, pinkish palpebral conjunctiva
C/L: ECE, clear breath sounds
CVS: DHS, (-) murmur
Abd: NABS, soft, no mass, no tenderness
GUT: (-) KPS bilateral
Ext: strong pulses
CNS: no neurologic deficit
Rectal: tight sphincteric tone, no mass, no rectal wall tenderness
Prostate- smooth , firm, elastic, non tender, enlarged
Differential Dx :
•Cystolithiasis
•Acute prostatitis
•Neurogenic bladder
Impression: R/I Benign Prostatic Hyperplasia ; Urinary tract infection
Venoclysis started w/ PNSS 1L at 20 gtts / min
Started w/ Co Amoxiclav 1.2 g slow IVTT q 12
Referred to a urologist for consult
Labs were taken
At the E.R
CBC
WBC 19.76
Neu 88
lymp 10
mono 2
HCT 36.2
HGB 12.5
PLT 251
On admission:U/A
Color Straw
pH 6.0
Sp. gr 1.010
Gluc neg
Protein
neg
Rbc 0-2
Wbc 0-2
Ec rare
Crea 6.53
BUN 70
Na 124
K 4.31
Ca 1.04
UTZ KUB
Obstructive Uropathy bilateral, etiology undetermined. Suggest IVPUrinary bladder – negativeNormal prostate gland (2.8 x 4.0 x 2.2 cm) volume 13.8 ml. Outline is smooth.
Chest xray : no significant findings
S : (+) urinary frequency, (+) dysuria, (-) fever
O: Abd: NABS, soft, no tenderness, distended bladder
A: Azotemia sec to Bladder Outlet obstruction
probably sec to BPH
P: FBC was inserted; initial drain 1.2L
NaCL 1 tablet TID
Co- amoxiclav 600 mg IVTT q 12
Course in the ward:Day 1
Repeat creatinine, HBAIC, Lipid profile, Uric acid
Urologic notes:
Azotemia sec to Bladder outlet obstruction sec to contracted bladder or high lying prostate gland
Recommendation: Cystoscopy - TURP
S: (-) urinary frequency, (-) fever
O: Bp – 100-120/70 Hr – 75-80 RR – 20 Temp- 36.5
Abd: NABS, soft, (-) tenderness
Urine output: 75cc / hr
Labs: Creatinine - 3.63 Uric acid – 8.7
HbAIC – 5.6
Lipid panel: Gluc- 112.10 LDL- 74
Chol – 125.87 Trig – 80.19
Day 2
A : Resolving Azotemia ; BPH ; Hyperuricemia
P: C0 Amoxiclav 600 mg IVTT q 12
Allopurinol 100mg 1 tab OD
NacL 1 tablet TID
S : no subjective complaints, (-) fever
O:
C/L : ECE, CBS
CVS : DHS , (-) murmur
Abd : NABS, soft, (-) tenderness
Urine output : 145 cc/ hr
Day 3
BP 110-130/70-80
HR 68 – 75 bpm
RR 19 – 20 cpm
Temp 36.5 – 36.8
Labs :
Creatinine – 1.86
A : Resolving Azotemia ; BPH ; Hyperuricemia
P : Co amoxiclav 1.2 g IVTT q 12
Dutasteride + Tamsulosin 500/4oomcg 1 cap OD
Allopurinol 100 mg 1 tab OD
For repeat creatinine
S : no subjective complaints, (-) fever
O :
C/L: ECE, CBS
CVS: DHS, (-) murmur
Abd: NABS, soft, (-) tenderness
Urine output : 139cc / hr
Day 4
BP 110-130/60-70
HR 75 – 80 bpm
RR 19 -21 cpm
Temp 36.6 – 36.8
Labs :
Creatinine: 1.43
Meds: Co amoxiclav 1.2 g IVTT q 12
Allopurinol 100 mg 1 tab OD
Dutasteride + Tamsulosin 1 tab OD
A : Azotemia resolved; BPH ; Hyperuricemia
P : Co amoxiclav 625 mg 1 tab BID p.o
Referred back to urologist for co management
S : no subjective complaints, (-) fever
O :
C/L : ECE, CBS
Abd: NABS, soft, (-) tenderness
Urine output : 14occ / hr
Day 5
BP 120/80
HR 75-80
RR 20
Temp 36.5 – 36.8
Meds: Co- amoxiclav 625 mg BID p.o
Dutasteride + Tamsulosin 1 tab OD
Allopurinol 1oomg 1 tab OD
A : Azotemia resolved ; BPH ; Hyperuricemia
P: Scheduled for Cysto – TURP
Referred to a cardiologist for CP clearance
Referred to anesthesiologist for anesthesia
For APTT, BT, Blood typing, Protime, Na, K
ECG 12 leads
S : (-) fever , good appetite, (+) BM
O :
C/L : ECE, CBS
CVS : DHS, (-) murmur
Abd: NABS, soft , (-) tenderness
Urine output : 12occ / hr
Day 6
BP 12o/70
HR 78 - 82
RR 20
Temp 36.5 – 36.7
Labs :
Protime – control 13.0, patient 12.8
103% activity, INR- .99
APTT – control 31.5, patient 31.9
BT – 1 min Blood type- A+
Na – 139 K- 3.56
ECG – sinus bradycardia w/ left atrial abnormality, non specific ST-T wave changes
Meds: Co amoxiclav 1 tab BID p.o
Dutasteride + Tamsulosin 1 tab OD p.o
Allopurinol 100mg 1 tab OD
A : BPH ; Hyperuricemia
P: CP cleared by cardiologist
Seen by anesthesiologist w/ pre op orders
NPO post midnight ; Bowel prep
Omeprazole 40mg IVTT x 1 dose at bedtime
S: (-) fever ; (+) hematuria
O :
C/L: ECE, CBS
CVS: DHS, (-)murmur
Urine output : 86cc / hr
Day 7 ; Post Op D 1
BP 130-140/70-80
HR 82-86
RR 19-22
Temp 36.4-36.7
Meds: Co amoxiclav 625 1 tab BID p.o
Dutasteride + Tamsulosin 1 tab OD
Allopurinol 1oo mg 1 tab OD
Tramadol 25 mg slow IVTT q 6 prn for pain
A : S/P Cysto-TURP ; Evacuation of bladder stone ;
BPH
P: Cystoclysis at moderate fast drip then decrease rate if with no more hematuria
> 15 grams of prostatic tissue were evacuated
Presence of urinary bladder stone < 2mm was evacuated
Intraoperative findings:
S : (-) fever ; (-) hematuria ; (-) BM
O:
C/L: ECE, CBS
CVS: DHS, (-) murmur
Abd: NABS , soft , (-)tenderness
Urine output : 55 cc / hr
Day 8 : Post op Day 2
BP 110-130/70-80
HR 78-84
RR 19-20
Temp 36.5-36.7
Meds:
Co- amoxiclav 625 mg 1 tab BID
Allopurinol 100 mg 1 tab OD
Dutasteride + Tamsulosin 1 tab OD
Tramadol 50 mg 1 tab TID prn for pain
A: BPH ; S/P Cysto TURP ; Evacuation of bladder
stone
P: IVF was consumed and terminated
S : (-) hematuria ; (-) fever, (-) BM
O :
C/L : ECE , CBS
CVS: DHS, (-) murmur
Abd: NABS, soft, (-) tenderness
Urine output : 96cc / hr
Day 9 ; Post op D3
BP 120/70
HR 75-80
RR 20
Temp 36.4-36.7
Meds : Co Amoxiclav 625 1 tab BID
Allopurinol 100 mg 1 tab OD
Dutasteride + Tamsulosin 1 tab OD
A: BPH ; S/P Cysto – TURP ; Evacuation of bladder stone
P: Cystoclysis was discontinued
FBC removed
• Able to void freely
• Discharged, improved
Final Dx :
Azotemia sec to Bladder Outlet Obstruction sec to BPH; Cystolithiasis S/P Cysto-TURP ; Evacuation of bladder stone
Biopsy : Nodular Hyperplasia ; Chronic prostatitis
Day 9 ; Post op D4
Most common disorder of the prostate gland
Proliferation of smooth muscles and epithelial cells
Normal aging process
May affect the quality of life
Cannot be prevented
Can be “treated”
Benign Prostate Hyperplasia
Anatomy
Name Fraction of gland Description
Peripheral zone (PZ)Up to 70% in young men
It is from this portion of the gland that ~70-80% of prostatic cancers originate.[14][15]
Central zone (CZ)Approximately 25% normally
This zone surrounds the ejaculatory ducts.
Transition zone (TZ) 5% at puberty
The transition zone surrounds the proximal urethra and is the region of the prostate gland that grows throughout life and is responsible for the disease of benign prostatic enlargement
Anterior fibro-muscular zone (or stroma)
Approximately 5%
This zone is usually devoid of glandular components, and composed only, as its name suggests, of muscle and fibrous tissue.
Peripheral zone
Transition zone
Urethra
Anterior lobe -roughly corresponds to part of transitional zone
Posterior lobe -roughly corresponds to peripheral zone
Lateral lobes - spans all zones
Median lobe -roughly corresponds to part of central zone
Lobes
Aging males
Fifth decade of life – 50% evidence of BPH
Increase in growth .5 - .8 g / year
80 years old – 90% evidence of BPH
Epidemiology :
Hyperplasia of stromal and epithelial cells causing enlargement of the gland
Dihydrotestosterone – mediator of prostate growth
A-1 adrenergic receptors on the smooth muscles of the stroma, capsule of the gland and bladder neck
Pathophysiology:
Serum testosterone
5 alpha- reductase
Serum Dihydrotestosterone
DHT – androgen receptor complex
Growth factors
Increased cell growth
Peripheral zone
Transition zone
Urethra
CausesCauses::
1)Static component – direct bladder outlet obstruction from the enlarged gland
2)Dynamic component – increased smooth muscle tone and resistance within the enlarged gland
Lower Urinary tract Syndrome
Voiding (obstructive) symptoms:
Weak urinary stream – common symptom of BPH
Prolonged voiding – linked to weak urinary stream and frequently accompanied by straining of abdominal muscles upon urination
Hesitancy – a delay between the voluntary attempt to void and the actual initiation of urination
Intermittency – involuntary disruption of the urinary stream during voiding
Incomplete emptying – may be accompanied by the continued desire to void or by pain or discomfort in the bladder area
Terminal dribbling – inability to effectively terminate voiding
Storage (irritative) symptoms:
Urinary frequency – associated with bladder irritation that presents as a need to void repeatedly during the day.
Nocturia – the need to void during sleeping hours more than once
Urgency – the need to urinate immediately
Urinary incontinence – involuntary loss of urine.
Complications:
Acute urinary retention
Renal insufficiency
Recurrent urinary tract infections
Gross hematuria
Bladder stones
History and Physical examination
Symptoms assessment
International Prostate Symptom Score Questionnaire
Diagnosis of BPH :
UrgencyOver the last month, how difficult have you found it to postpone urination?
0 1 2 3 4 5
Weak streamOver the past month, how often have you had a weak urinary stream?
0 1 2 3 4 5
StrainingOver the past month, how often have you had to push or strain to begin urination?
0 1 2 3 4 5
Mildly symptomatic : 0-7
Moderately symptomatic : 8-19
Severely symptomatic : 20-35
IPSS score :
Detects size , consistency , contour
Screening exam for prostate CA
Sphincteric tone – rule out neurologic disease
Digital Rectal Exam:
Urinary bladder – stones ; tumors ; post residual volume ;
Kidneys – size ; stones
Prostate – size ; volume ; calcifications
Ultrasound :
Urinalysis
Prostate Specific Antigen – to rule out prostatic adenocarcinoma
Serum creatinine (optional)
Laboratory :
A. Watchful waiting / Active surveillance
- mild symptoms of LUTS (IPSS score < 8)
- moderate-severe symptoms of LUTS
(IPSS score >8)
- not bothered by their symptoms
Management (AUA guidelines)
Behavioral Modifications:
- reduction of fluid intake (especially at bedtime)
- moderation of alcohol and caffeine intake
- use of time voiding schedules
- discontinuation of drugs that can aggravate
bladder or outlet obstruction
e.g. anhistamines , decongestants
B. Medical management
- moderate-severe symptoms of LUTS
(IPSS score >8)
- bothered by symptoms
C. Surgical intervention
- moderate-severe symptoms of LUTS
(IPSS score >8)
- bothered by symptoms
- affect the quality of life
- complications of BPH
- failed medical therapy
- patient’s choice
Acute urinary retention
Bladder stones
Upper urinary tract dilatation
Renal failure
Absolute indications for surgery
Hematuria
Large post voidal residuals
Recurrent urinary tract infections
Relative Indications:
Benign prostate hyperplasia
Enlarged Normal Enlarged Enlarged
Prostate Prostate Prostate Prostate
Mild sx Mild-Mod Mod- Sev Mod-Sev
No bother Bother Bother Acute Urinary
Retention
Watchful A- blockers Comb Tx Catheterization
Waiting Comb tx
Modifications
Tx failed Trial voiding
Failed
Min Invasive procedure
Surgery
A. Alpha blockers
Non selective and selective alpha 1- adrenergic
receptor blockade
Relieves lower urinary tract symptoms by:
- relaxation of smooth muscle tone in prostatic
stroma and bladder neck
- relaxation of bladder smooth muscle
- central action
Medical therapy
Non selective alpha blockers:
1)Phenoxybenzamine
Selective short acting alpha 1 blockers:
1)Alfuzosin 2.5 mg, 10 mg – no anejaculation
2)Prazosin
Selective long acting alpha 1 blockers:
1)Terazosin 1 mg, 2 mg, 5 mg – dose dependent
2)Doxazosin 4 mg, 8 mg – dose dependent
Partially subtype ( alpha-1a) selective agents
1)Tamsulosin 200 mcg, 400 mcg – uroselective
2)Silodozin – new drug
Postural Hypotension – most common
- dizziness
nasal congestion
Headache
Ejaculatory dysfunction
Side effects:
Intraoperative Floppy Iris Syndrome
-Triad of progressive intra op miosis, billowing of a flaccid iris and iris prolapse toward the incision site during phacoemulsification for cataracts
-Common in tamsulosin : 43%-90%
Caution:
Inhibition of DHT receptor complex formationProfound decrease in the concentration of DHTDecrease in prostate size
1)Dutasteride 500 mcg2)Finasteride 5mg – refractory hematuria sec to prostatic bleeding
5 a- reductase enzyme inhibitor
Decrease libido
Erectile dysfunction
Ejaculation disorder
Adverse effects:
Widely used for treatment of various ailments
Readily available
cheaper
Less adverse effects
Phytotherapy
Saw palmetto berries – American dwarf palm
Antiandrogenic effect
Inhibition of 5 a reductase enzyme
Anti inflammatory
Improve subjective complaints
Dosage : 160 mg twice a day
Adverse effects : G.I discomfort
American Urologic Association
- Available data do not suggest that saw palmetto has clinical meaningful effect on LUTS sec to BPH.
- Further clinical trials are still in progress
Recommendation:
- No dietary supplement, phytotherapeutic agent or other non conventional therapy is recommended for the management of LUTS sec to BPH
Alpha blockers + 5a reductase enzyme inhibitor
Finasteride + Doxasozin
Dutasteride + Tamsulosin
Medical Therapy of Prostate Symptoms (MTOPS)
large scale, long term study with a recruitement of 3047 men with BPH and a mean follow-up of 4.5 years.
Combination therapy
Found that combination therapy with alpha 1 blocker and 5 a- reductase inhibitor provided benefits over either drug as monotherapy in terms of reduction in the risk of clinical progression
Key Findings:
Decreased risk of progression
- a- blockers – 39%
- 5 a- reductase inhibitor – 34%
- Combination therapy – 66%
Decrease risk of acute urinary retention
- combination therapy - 81%
- 5 a- reductase inhibitor – 68%
- a- blockers – 35%
Decrease in prostate volumes
- greatest reduction in combination therapy and 5 a reductase inhibitor
Adverse effects :
None of the adverse effects occurred with a frequency of > 6 events per 1oo patient-years on follow-up
Discontinuation rates is lesser on combination therapy (18%) than in a- blockers (27%) and 5-a reductase inhibitor (24%)
Conclusion:
Combination therapy has been shown to provide fast symptom relief, reduced prostate growth, reduced risk of acute urinary retention and the need for BPH related surgery
Combination of Avodart and Tamsulosin trial (CombAT) study
-66% reduction in the risk of acute urinary retention and BPH related surgery
-44% decrease in clinical progression of the disease
Transurethral resection of the Prostate
Gold standard for obstructive BPH
Standard of care when all other methods fail
Surgery
Surgical removal of the prostate’s inner portion through endoscopic approach through the urethra under general / spinal anesthesia
Indications:
a) refractory urinary retention
b)Renal insufficiency sec to bladder outlet obstruction
c)Recurrent UTI
d)Recurrent gross hematuria
e) Bladder calculi
f) Permanently weakened or damaged bladder
Complications:
a)TUR syndrome – dilutional hyponatremia
b)Hematuria
c)Erectile dysfunction
d)Bladder neck contracuture
e)Irritative voiding symptoms
Open Prostatectomy
Surgical removal of the prostate via suprapubic or retropubic incision in the lower abdominal area
Indicated in very large prostate
Prostate volume of 80-100 ml
a) Significant risk of blood loss
b) Need for blood transfusion
c) Erectile dysfunction
d) Retrograde ejaculation
e) Longer hospital stay compared to TURP
Complications
1) Transurethral needle ablation of the prostate
2) Transurethral microwave thermotherapy
3) Transurethral Holmium laser ablation
4) Transurethral Holmium laser enucleation
5) Transurethral vaporization
6) Photoselective vaporization
7) Transurethral incision of the prostate
Minimal invasive procedures
Thank you!