LEARNING OBJECTIVES:
 Case study
 What is BOO?
 Pathophysiology
 Clinical features
 IPSS
 BPH
 Investigations
 Treatment
CASE STUDY:
 A sixty year old male came to opd with
severe difficulty in voiding , weak urinary
stream & straining his ultrasound reveals 55
gm prostate & residual urine of 70ml . His PSA
is 2-4 gm per ml.
BOO
It’s urodynamic concept of low flow rates and
high intravesical pressures.
Causes:
*BPH.
*CAP.
*bladder neck stenosis.
*urethral stricture.
*neuropathic conditions.
Pathophysiology
 Boo over time will result in..
increase in the intravesical voiding pressure
(>80 cm H2O), bladder muscle hypertrophy
(trabiculation, sacculation and diverticulum
formation).
 High pressure may transmit to the upper tract
causing hydroureter, hydronephrosis and renal
insufficiency.
 Boo results in incomplete bladder evacuation
(residual urine) which predisposes to UTI and
stone formation.
 Decrease uro flow rate under 10 ml /sec
Symptomatology (LUTS)
 Obstructive:
Hesitancy
Straining
Weak stream
Intermittency.
Post voiding dribbling.
Retention of urine.
 Irritative:
Frequency.,nocturia
Urgency & incontinence.
Benign prostatic hyperplasia
Benign prostatic hyperplasia
BPH
Third most common urological
pathology.
Starts at late 30s & appear clinically at
60s.
Theories:
Hormonal: DHT, growth factor.
Neoplastic: fibromyoadenoma.
Typically affects submucosal glands at
transitional zone.
IPSS
[international prostatic symptom score ]
Precipitating causes for retention
Severe pain. MI, joint pain.
Psychological upset.
Cold exposure.
Constipation.
Drugs
Anticholenergic & diuretic
,decongestant,antihistamin
 Ignoring first desire for urination.
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Clinically
Usually normal.
Distended bladder.in acute or chronic
retention
PR ex: enlarged prostate, smooth,
regular, firm, maintained median
sulcus and mobile rectal mucosa
Normal anal sphincter tone.
Normal bulbocovernosus reflex
Investigations:
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•
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Serum Creatinine
X ray KUB
Ultrasound Scan
IVU
PSA (0-4 mg/ml)
TRUS (TRANSRECTAL ULTRASOUND)
Urodynamic Studies
Cystoscopy: enlarged prostate, trabiculation &
stones.
Size of the prostate has no relation with the
severity of the symptom but the degree of
urethral compression.
Treatment
Conservative:
Avoid ppt factors.
Treat pains.
Treat UTI.
Αlfa blocker: prazocin 1 mg, terrazocin 2mg,
doxazocin 2mg.tamsulusin,alfuzosin At night
S/E hypotension, 1st dose syncope.
5 α reductase inhibitors: fenasteride, prosteride
5 mg/day > 6 months.
S/E impotence.
Usually used in large gland
Semi surgical:
TUMT (trans urethral microwave thermotherapy)
HIFU ( high intensity focused u/s)
TUIP (Trans urethral incision of prostate)
TUNA (Trans urethral needle ablation)
Prostatic stents
TU baloon dilatation
TUMT
STENT
TUNA
Surgical treatment
Endoscopic:
TURP
Laser
Open surgery:
Transvesical prostatectomy.
Rertopubic prostatectomy
INDICATION OF SURGERY IN
BPH
 SEVERE SYMPTOMS
 FAILURE OF MEDICAL TREATMENT
 COMPLICATIONS LIKE:
 ACUTE URINARY RETENTION

CHRONIC RETENTION

REPEATED HEMATURIA

REPEATED UTI

VESICAL STONE

RENAL IMPERMENT DUE TO CHRONIC
RETENTION
TURP
Transvesical
retropubic
BEFORE TURP
TURP
AFTER
Complications:
Early:
Hemorrhage.
Infection.
Wound infection[in open prostatectomy]
Late:
Urethral stricture
Bladder neck contracture
Retrograde ejaculation.
Incontinence.
Impotence.
Recurrence of BPH. After 5-10 years.
Carcinoma of the prostate
CAP
One of the most common malignant tumor
affecting males over the age of 65 in western
countries.
Pathology
95% of the tumor are adenocarcinoma and
derived from acinar epithelium
75% of CAP arise from peripheral zone.
grading:
Gleason’s grade based on the degree of
glandular differentiation and growth pattern.
Spread
Direct invasion: to nearby structures.
Denonvvilliar’s fascia act as barrier.
Lymphatic: internal, external & common iliac
Blood: to the lower lumber vertebrae & pelvic
bones due to reverse blood flow from
vesicoprostatic plexus to the emissary veins
of the bones during coughing & sneezing
(OSTEOBLASTIC)
Osteoblastic lesion of secondary CAP
Presentation
 Accidental during histopathological ex after
prostatectomy.
 During PR ex
 High PSA
 BOO.
 Metastatic: back ache, sciatica, paraplegia
or pathological fractures..
*
BPH
CAP
Younger age
older
Symptoms slowly
progressive
Rapid progression
Usually no back or
bone pain
More back ache &
neurological
symptoms
Smooth rubbery
prostate with sulcus
Hard irregular prostate
with obliterated sulcus
Rectal examination:
Stony hard irregular prostatic nodule,
obliterated median sulcus, difficulty in
moving the rectal mucosa over it and fixity.
Normal PR ex does not exclude CAP.
prostatic cancer
39
Investigations
PSA: prostatic tumor marker for diagnosis and
follow up, it may also increase in prostatitis and
BPH.
10 ng/ml normal,
10-15 suspicious.
>15 is diagnostic.
Acid phosphatase: prostatic fraction.
Alkaline phosphatase: in bone metastasis.
Radiological investigations
Plain X ray: osteoblastic lesion.
Bone scan: hot areas (active).
CT scan.
TRUS & biopsy (sixtant biopsy).
prostatic cancer
42
Treatment
Watchful waiting:
Radical prostatectomy:
Enblock surgical removal of the entire prostate,
seminal vesicles and pelvic lymph nodes. The
bladder anastomosed to the urethra.
Indicated for early disease and healthy fit pt.
2. Radical prostatectomy
prostatic cancer
44
Radiotherapy
external beam & brachytherapy
Indication:
1- Locally advanced disease.
2- Unfit patient for surgery.
3-Symptomatic metastases to relieve pain.
3. Radiation therapy
external beam
therapy
brachytherapy
prostatic cancer
46
Hormonal therapy
Its trearment of choice for metastatic tumor
Cap is hormonal dependant (androgen), and
about one third of tumors are hormoneinsensitive.
Androgen ablation may change the course of
the disease.
Methods of androgen ablation
surgical
Bilateral orchiectomy: complete or subcapsular.
medical
LHRH agonist: (Zoladex)/28 days SC.
Anti androgen: (Nilutemide) 250 mg/6h.
.
RESEARCH:
According to research done in 2015 by wah
medical collage, wah cantt
 Of the 1500 patients in the study, 810(54%)
were females and 690(46%) were male.
Lower urinary tract pathologies were found in
480(32%) patients.
 The most common pathology among males
was enlarged prostate in 127(8.4%) patients.
Among females, urethral stenosis was the
most common pathology in 57(3.8%)
patients. Transitional cell carcinoma was seen
in 57(3.8%) patients having haematuria with
inconclusive ultrasound and intravenous
urography. All patients tolerated the
procedure well.
 Aging Population= More BPH
 Not all Male LUTS=BPH
 Not all BPH=LUTS
 Consider Combination Therapy
 Quality of life issues
prostatic cancer
52
prostatic cancer
53
Thank you