Bladder Outlet Obstruction and BPH

BPH / CA PROSTATE & BOO

Introduction

Anatomy – 5 lobes. Median/Posterior – (BPH/Cancer) Function ? Hormone response – Estrogen like Enlargement – Inflammation / growth Neoplastic / Non neoplastic growth. BPH / Cancer.

Enlargement of Prostate:

BPH – Benign Prostatic Hyperplasia Inflammations – infections Neoplasms – Carcinoma.

Introduction

Common non-neoplastic lesion. Involves peri urethral zone. BPH is common as men age. 75% among men aged 70-80years Over 90% in people aged over 90y Rare before the age of 40y. ? Physiological …

BPH

Prostate enlargement According to NIH, BPH affects 50% of men

>60 years of age Affects >90% of men over 70 years of age Men who have undergone bilateral

orchiectomies do not develop BPH

Peripheral zone

Transition zone

Urethra

What is Benign Prostatic Hyperplasia?

Peripheral zone

Transition zone

Urethra

BPH-Pathophysiology:

Excess hormones – estrogen like. Nodular hyperplasia of glands & stroma. From normal 20 to 30 50 to 100 gm. Press upon the prostatic urethra. Obstruction - difficulty on urination Dysuria, retention, dribbling, nocturia Infections, hydronephrosis, renal failure. Not a premalignant condition*

BPH - Mechanism

Hormonal imbalance with ageing. Estrogen sensitive peri-urethral glands. Accumulation of dihydrotestosterone in the

prostate and its growth-promoting androgenic effect

BPH-Morphology

Microscopically, nodular prostatic hyperplasia consists of nodules of glands and intervening stroma. (Mostly glands)

The glands variably sized, with larger glands have more prominent papillary infoldings.

Nodular hyperplasia is NOT a precursor to carcinoma.

BPH-mechanism of obstruction:Median lobe (3rd lobe) Ball valve mechanism

BPH-Complications:

1. Urethral compression2. Ball valve mechanism3. Bladder hypertrophy4. Trabeculation5. Diverticula formation6. Hydroureter – bilateral7. Hydronephrosis

BPH-Bladder Gross – Identify Cues?

Trabeculations Hypertrophy of wall Stone - urolithiasis Inflammation Median lobe- ball valve. Enlarged prostate.

BPH-Bladder morphology:

Hypertrophy Trabeculation Median lobe

protrusion.

Benign Prostatic Hyperplasia:

Normal Prostate:

Nodular BPH:

PATHOGENESIS & PATHOLOGY

Finding at Cystoscopy of Stage of Compensation Trabeculations of bladder wall Trigonal hypertrophy and prominent intrureteric ridge Relative obstruction at UV junction due to in intra vesical

portion of ureter hydroureteronephrosis Cellules

Uptil superficial muscle layer Sacculation

Beyond musculature Diverticula

Beyond bladder serosa Mucosal changes of infection (cystitis)

PATHOGENESIS & PATHOLOGY

Stage of Decompensation Detrusor decompensation due to progressive

in outlet resistance Residual urine / chronic retention

C. Effect on Upper Tract Ureter

Trigonal hypertrophy in resistance to intramural ureter back pressure on ureter and kidney Dilatation

PATHOGENESIS & PATHOLOGY

With decompensation, residual urine stretching of uretero trigonal complex further in resistance to flow at UVJ intravesical pressure directly transmitted to renal pelvis

In stage of compensation ureteric musculature hypertrophies with in peristaltic activity elongation and tortuosity of ureter fibrous bands at kinking of ureter secondary obstruction of ureter which will not be relieved even if primary cause is removed.

In Decompensation Stage Ureteric wall attenuation occurs loss of

contractility dilation

Physiologic Explanation of Symptoms of Bladder Neck Obstruction

Stage of compensation Stage of decompensation

Normal detrusor pressure – 20-40

With BOO – 50-100 cm of H2O pressure

Like HEART, receives fluid & expels it forcefully by contraction

Physiologic Explanation of Symptoms of Bladder Neck Obstruction (Contd.)

A. Compensation Phase1. Stage of Irritability: Force & calibre of stream is maintained

Detrusor hypertrophy make bladder irritable. Difficult to suppress normal feeling of voiding bladder spasm occurs. Cause urgency / urge incontinence and frequency.

2. Stage of Compensation: - Hesitancy added

- Some in force and size of stream

- Terminal stream is poor due to exhaustion of detrusor muscle.

Physiologic Explanation of Symptoms of Bladder Neck Obstruction (Contd.)

2. Chronic decompensation R.U. functional capacity of

bladder loses power of contraction Ch. retention with over flow incontinence

What’s LUTS?Voiding (obstructive)symptoms Hesitancy Weak stream Straining to pass urine Prolonged micturition Feeling of incomplete

bladder emptying Urinary retention

Storage (irritative orfilling) symptoms Urgency Frequency Nocturia Urge incontinence

LUTS is not specific to BPH – not everyone withLUTS is not specific to BPH – not everyone withLUTS has BPH and not everyone with BPH has LUTSLUTS has BPH and not everyone with BPH has LUTS

Diagnostic Findings DRE-large, rubbery, nontender PSA may be elevated UA Urodynamic studies assess urine flow IVP Rectal ultrasound Renal function tests CBC/Coagulation studies

Medical Management “Watchful waiting” Medications

5-alpha reductase inhibitors Inhibit production of DHT Finasteride (Proscar) Dutasteride (Avodart)

Alpha blockers Dilate smooth blood vessels and relax smooth muscles in prostate

and bladder neck Tamsulosin (Flomax) Terazosin (Hytrin) Doxazosin (Cardura)

Combination therapy proven superior in treatment of BPH and is now recommended by American Urologic Association.

Surgical Treatment

Transurethral resection of prostate (TURP) Gold standard Surgical procedure requiring spinal or general

anesthesia Resectoscope inserted through urethra Gland removed in small chips by electrical cutting

loop Inpatient hospitalization required

Other BPH Surgical Management

TUIP (transurethral incision of prostate) TUMT (transurethral microwave therapy)

Other BPH Surgical Management

Laser therapy TUNA (transurethral

needle ablation) Open prostatectomy Balloon dilatation Prostatic stents TUVP (transurethral

vaporization)

Adenocarcinoma Prostate:

Adenocarcinoma of the prostate is common in elderly men.

It is rare before the age of 50, but seen in over half of men 80 years old.

Many of these carcinomas are small and clinically insignificant.

Is second only to lung carcinoma as a cause for tumor-related deaths among males.

Adeno-Ca Prostate

Adeno-Carcinoma + BPH

BPH with Adenocarcinoma:

Adenocarcinoma Prostate: (HP)

Diagnosis:

Digital examination – hard, gritty, fixed. Ultrasonography (transrectal) - Tumor Marker – PSA Biopsy - TURP None of these methods can reliably detect

small cancers. Occult cancer is more common than

clinical ca.

Prognosis of Adenocarcinoma:

Grade & Stage Prognosis. Urinary obstruction, metastasize to lymph

nodes and bones. Bladder, kidney damage. Hematuria. Spread to Lungs or liver – rare.