Bengin Prostatic Hyperplasia _ صفاء

Question 1

what’s the location of the prostate ?

Answer 1

The prostate is located just below the bladder and in front of the rectum. It is about the size of a walnut

located between the bladder and the penis. The prostate is just in front of the rectum. The urethra runs through the center of the prostate, from the bladder to the penis, letting urine flow out of the body. The prostate secretes fluid that nourishes and protects sperm.

Question 2

what’s the causes of BPH ?

Answer 2

Hyperplasia of epithelial and stromal components of prostate

Question 3

what’s the sequle of the disease ?

Answer 3

1-Hyperplasia of epithelial and stromal components of prostate

2- then obstruction of urinary outflow in bladder

3- Increased activity of detrusor muscle(hypertrophy of the mucle )

4- this then lead to obstructive symptomas as Frequency, nocturia ,Poor flow and intermittent stream

and irriative symptomas as Hesitation and post voiding dribbling

Question 4

The prostate is divided into several lobes

Answer 4

the anterior lobe

the median lobe

the lateral lobes

and the posterior lobe.

Question 5

The prostate gland is composed of different types of zones:

Answer 5

The peripheral zone

The central zone

The transition zone

Question 6

whats the benfit of the zones ?

Answer 6

CA of the pancreas arise from the periphery while

begnin arise from the transtional zone

Question 7

why the BPH increase after age of 30 ?

Answer 7

beca

Question 8

what’s the type of facia in the prostate ?

Answer 8

The rectoprostatic fascia (Denonvilliers’ fascia)

is a membranous partition at the lowest part of the rectovesical pouch. It separates the prostate and urinary bladder from the rectum.

prevent the invasion to the rectum

Question 9

why pt over age of 50 are more liable for the BPH ?

Answer 9

-because with increase the age the testestrone will decrease (testes) but the 5alpha reductase enzyme increase which convert the the testesrone into the dyhydrotestrone which is more potent (long half life )
will inhibit the apptosis and increase the growth and development of the cells as the basal and the luminal cells

Question 10

Prevalence of BPH …

Answer 10

+Men > 50 = 41% have symptoms of LUTS

+Only 18% have a diagnosis because of educational level of the pt so many of them diagnosis as UTI or overactive bladder

+Only 10% aware of drugs or surgery that will help it

Question 11

pt Men > 50 will 41%

Answer 11

41% have symptoms of LUTS

Question 12

Risk factors of the BPH

Answer 12

Age over 50

obesity they have relation with hyperlipdema because the precsor of the androgen is the cholestrol

Question 13

Differential diagnosis of BPH …

Answer 13

-Poorly controlled diabetes
because DM lead to destruction of the scaral plexus that supply the detrusor muscle of the bladder

-Urinary tract infections
specailly the trigiontis which the most senstive part that lead to irrative symptomas

-Neurological disorders
as neurogenic bladder cause spastic to the bladder and obstruction

-Overactive bladder

-Drugs – diuretics, anticholinergics, antidepressants
these drugs act agnist the parasympathtic system and lead to increase the symathic and spasm of the bladder neck with retention

• Lifestyle factors – caffeine, alcohol, xs fluids
• Abacterial prostatitis

+bladder may be over active , neurogenic or infected

Question 14

Abnormal symptoms in BPH indicated …

Answer 14

that the pt should be referred to urologist for do futher assessment

Question 15

what’re the Abnormal symptoms …

Answer 15

-Urinary incontinence
involuntary leakage of urine

• Retention
• Dysuria
• Haematuria

-Acute change in symptoms
some of sometimes changes from mild to sever

Question 16

pt with BPH and urinary retention indicate

Answer 16

paraxosmal incontinence

Question 17

Examination of BPH

Answer 17

• enlarged bladder
  most important one

-enlarged kidneys
retention of urine

-constipation
the prostate in the front of the ampula of rectum

• but may be the prostate is palpate in the suprapubic area

Rectal examination 
--------------------------------
Size and consistency of prostate gland
if the firm is BPH 
But if hard its CA

Question 18

difference between the acute and chronic retention ,,

Answer 18

acute is painful ,lead to enlarge bladder

while the chronic is less painful , the bladder enlagment lead to the bladder reach the epigastrium

Urinary retention is the inability to voluntarily urinate. Acute urinary retention is the sudden and often painful inability to void despite having a full bladder. 1 Chronic urinary retention is painless retention associated with an increased volume of residual urine and bladder that remains palpable after voiding

Question 19

Investigations pf BPH …

Answer 19

-Fasting blood sugar
to exclude the DM

• erythrocyte sedimentation rate (ESR)
• Urea and electrolytes (U&Es)
• Renal function test
• complete blood count
  for infection

level rises with increasing volume of prostate gland

• Infection
• haematuria

this special investigation done if we have suspison of ureter stricture rather than the prostate
or pt have neurogenic bladder

assess the dtrusor muscle contraction and tell us if the the removal of the prostate is indicated of not

Ultrasound 
-----------------------
-assess the size of prostate 
-congensity 
BPH have iso- echoic picture while CA have hypo-ehoic picture 

• estimate residual urine
  by draining the bladder with a thin flexible tube (catheter) or by using ultrasound normal is (0-20cc )
  less than 50 mL is considered normal

Visual inspection of bladder and uerethra

• used in dysuria or haematuria because pt may have tumor in the bladder in addation to the BPH
• see if there is uerethra stricture

+ Renal function test
include
2 tests: ACR (Albumin to Creatinine Ratio) and GFR (glomerular filtration rate). GFR is a measure of kidney function and is performed through a blood test. … ACR is a urine test to see how much albumin (a type of protein) is in your urine.

+Post-void residual volume (PVR) is the amount of urine retained in the bladder after a voluntary void

Question 20

what’re the special investigation

done before the prostate removal

Answer 20

• Uroflowmetry
• Bladder pressure studies (cystometry)

Question 21

Uroflowmetry

Answer 21

max flow rate and volume of residual urine after voiding
this special investigation done if we have suspison of ureter stricture rather than the prostate
or pt have neurogenic bladder

– low flow rate indicates need for TURP

+Transurethral resection of the prostate (TURP) is a surgery used to treat urinary problems that are caused by an enlarged prostate. An instrument called a resectoscope is inserted through the tip of your penis and into the tube that carries urine from your bladder

Question 22

Bladder pressure studies (cystometry)

Answer 22

pressure measurement during filling and emptying (cystometry) gives information on over/under activity of detrusor muscle and obstruction of bladder outlet. Predicts response to treatment. Use antimuscarinics for over activity and turp for bladder outlet obstruction

assess the dtrusor muscle contraction and tell us if the the removal of the prostate is indicated of not

Question 23

Ultrasound

Answer 23

-assess the size of prostate
-congensity
BPH have iso- echoic picture while CA have hypo-ehoic picture

• estimate residual urine
  by draining the bladder with a thin flexible tube (catheter) or by using ultrasound normal is (0-20cc )
  less than 50 mL is considered normal

Question 24

Urethroscopy

Answer 24

Visual inspection of bladder and uerethra

• used in dysuria or haematuria because pt may have tumor in the bladder in addation to the BPH
• see if there is uerethra stricture

Question 25

Assesment of the BPH

Answer 25

by international prostate symptom scale.
IPSC
it’s 7 symptoms for each 5 score

1 – 7 mild—–conservative TRT

8 – 19 moderate——-
20 – 35 severe———- both need surgery

this need hight awarnace of the pt

Question 26

so the surgery of BPH depend on

Answer 26

assessment and special investigation

Question 27

mangment of the BPH …

Answer 27

start from simple into more complex

Lifestyle modification
-----------------------------------
Reduce fluid intake
Stop diuretics if possible 
Avoid xs night time fluid intake/caffeine /alcohol
Empty bladder before long trips/meetings

Diabetes
UTI

Drug therapy
-------------------------
Alpha blockers as 
Tamsulosin and alfuzosin
Improve bladder and prostate smooth muscle tone
More effective 

5 alpha reductase inhibitors
Reduce prostate volume
Reduces risk of prostate cancer, increases risk of high grade disease

Combined therapy
Men with large prostate > 40g or PSA >4 or moderate to severe symptoms combined therapy will prevent 2 episodes of clinical progression per 100men over 4yrs. Much less effective for men with smaller prostates

Surgery
-------------------------------
-TURP( Transurethral resection of the prostate )
Greatest improvement in symptoms
5% severe haemorrhage risk
Requires GA

• Ultrasound
• Laser
• microwave

Question 28

Men with symptoms of urinary urgency, frequency, small, urine volumes and nocturia in the absence of serious obstructive symptoms are categorised as

Answer 28

over active bladder

Question 29

over active bladder

Answer 29

Men with symptoms of urinary urgency, frequency, small, urine volumes and nocturia in the absence of serious obstructive symptoms are categorised as

Question 30

Alternative energy sources for TURP

Answer 30

Ultrasound
Laser
microwave

Question 31

Adverse effects of surgery

Answer 31

• Loss of ejaculation
• Erectile dysfunction
• Retrograde ejaculation
• Incontinence
• Stricture formation
• Urinary retention