BPH, Inflammatory diseases of prostate

As. Prof. Lukáš Bittner M.D., FEBU

Urologická klinika 3. LF UK a FNKV

lukas.bittner@fnkv.cz

BPH (Benign Prostatic Hyperplasia)

Most common „benign tumor“ in menPrevalence

20% age 41-50 50% age 51-60›90% older than 80

Prevalence of BPH

Etiology BPH

MultifactorialEndocrine controlled

Positive correlation between levels of fT and E and volume of BPH

Increase of E causing induction of androgen receptor, ꜛsensitivity

BPH

Pathology of BPH

BPH develops in transition zoneHyperplastic process, increase of cell No.Nodular grown pattern of stroma +

epitheliumStroma composed of collagen and smooth muscle • Smooth muscle target for alfa- blockers• Epithelium target for 5-alfa –reductase inhibitors• Collagen does not respond to medical Th

Anatomy of the prostate

Pathophysiology of BPH

Obstruction

Mechanical obstruction• Intrusion of prostate into the urethral lumen or bladder

neck= higher bladder outlet resistance

Dynamical obstruction • prostatic stroma is rich in adrenergic nerve supply, level

of autonomic stimulation sets the tone of prostatic urethra

Surgical anatomy

3 lobes2 lateral1 median (impalpable)

Prostate 25y.o.

Prostate 50y.o.

Clinical Findings

Hesitancy*Decreased force and

caliber of streamSensation of incomplete

bladder emptyingDouble voidingPost void dribbling

* Difficulty in beginning

UrgencyFrequencyNocturia

=LUTS Low Urinary Tract Syndrom

IPSS score

0-7 Mild8-19 Moderate20-35 Severe

Examination

DRES PSAUrinalysisPost void residuum- USGUFM

Uroflowmetry (UFM)

UFM terminology

UFM findings

Differential Diagnosis

Urethral strictureBladder neck contractureBladder stoneCaPInfectionTumor of bladder

Absolute surgical indication

Refractory urinal retention

Recurrent urinary tract infection from BPH

Gross hematuria from BPH

Bladder stones from BPHRenal insufficiency from

BPHLarge bladder diverticula

from BPH

Medical therapyof BPH

IPSS mild symptoms- watchful waiting

Alpha-blockers5-alfa reductase inhibitorsPhytotherapy

Alpha-blockers

Prostate and bladder base contains alpha-1 adrenoreceptorsShows contractile response

Fast onsetTime limited efficiencySide effects: hypotension, dizziness,

headache, retrograde ejaculationTamsulosin, Alfuzosin- alpha 1a selective,

once daily

5-alfa reductase inhibitors

Block conversion of T to dihydrotestosteronAffects epithelial component

Reduction of size (6monts 20%)PSA is reducedLate onset, long actingReduced risk of acute retention and need of

surgerySide effects: erectile dysfunction, decreased

libido, gynekomastiaFinasteride, Dutasteride, once daily

Phytotherapy

Saw palmeto berry (serenoa repens)Bark of Pygeum africanum

No benefit in randomised trials

Surgical therapy

Conventional therapyTransurethral resection of prostate (TURP)Open simple prostatectomy

Minimal invasive therapyLaser therapyTUNATUMTStents

Surgical treatment algorithm

Transurethral resection of Prostate (TURP)

TURP

TURP

Shorter hospital stayMinimal to moderate

bleeding

Strictures of urethra5% of EDTUR sy.

TUR Syndrome

The intrusion of salt-free irrigation fluid in open veins or perforation of the prostate capsule can cause a volume overload and dilutional hyponatremia (<125 mmol/l) of the patient.

SymptomsConfusionnausea and vomitingarterial hypertensionBradycardiapulmonary edema and impaired vision.

TUR Syndrome

Risk factorsProstate volume over 45 mlresection time over 90 minheight of the irrigation fluid by the patient over 70

cm. Lab controla

Sodium levelTreatment

Furosemide is given (20–40 mg i.v.)hypertonic NaCl solution slowly

Transvesical prostatectomy (TVPE)

TVPE

TVPE

Safe for urethraShorter operation time

Moderate to severe bleeding

Longer hospital stay

Acute bacterial prostatitis

Acute prostatitis

Associated with UTIascending urethral infectionReflux of infected urine from bladder

Most common urologic Dg. In men ≤50

Presentation

Abrupt onsetFeverChillsMalaiseBack/rectal/perineal painUrinary sy

• Frequency• Urgency• Dysuria

Findings

DRE- tender, warm, enlarge glandUrinalysis WBCSerum: leukocytosis, elevation PSA

Avoid prostatic massage, urethral catheterization

Causative organisms

E. coliProteusKlebsiellaPseudomonas

Treatment

Trimethoprim and fluoroquinolonesGood penetration4-6 weeks

If urine retention present- placement of suprapubic catheter

Chronic bacterial prostatitis

Present withDysuriaUrgencyFrequencyRecurrent UTI

DREOften normal

PSA may be elevated

4- Cup Test (Stamey)

Collect firs 10 mL voided urine (VB1)Discard next 100mLCollect next 10 mL (VB2)Massage prostate and collect prostate

expressate (ESP)Collect first 10 ml of voided urine after

massage (VB3)

interpretation

All specimen ≤103 CFU/mL not bacterial prostatitis

VB3 of EPS › 103 CFU/mL bacterial prostatitis

Only VB1 pos.- urethritisALL positive- treat UTI and repeat

Alternative – voided specimen before and after prostatic massage

Treatment of Chronic Prostatitis

Trimethoprim and fluoroquinolonesDuration of Th 3-4 months

Alfa blocker will reduce symtom recurrences