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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:
Introduction
? 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
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
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. 2. 3. 4. 5. 6. 7. Urethral compression Ball valve mechanism Bladder hypertrophy Trabeculation Diverticula formation Hydroureter bilateral Hydronephrosis
Trabeculations Hypertrophy of wall Stone - urolithiasis Inflammation Median lobe- ball valve. Enlarged prostate.
BPH-Bladder morphology:
Normal Prostate:
Nodular BPH:
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)
Detrusor decompensation due to progressive in outlet resistance Residual urine / chronic retention
Ureter
Trigonal hypertrophy in resistance to intramural ureter back pressure on ureter and kidney Dilatation
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. Ureteric wall attenuation occurs contractility dilation loss of
In Decompensation Stage
20-40
Compensation Phase
1. 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.
Whats LUTS?
Voiding (obstructive) symptoms Hesitancy Weak stream Straining to pass urine Prolonged micturition Feeling of incomplete bladder emptying Urinary retention Storage (irritative or filling) symptoms Urgency Frequency Nocturia Urge incontinence
LUTS is not specific to BPH not everyone with LUTS 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
Inhibit production of DHT Finasteride (Proscar) Dutasteride (Avodart) Dilate smooth blood vessels and relax smooth muscles in prostate and bladder neck Tamsulosin (Flomax) Terazosin (Hytrin) Doxazosin (Cardura)
Alpha blockers
Combination therapy proven superior in treatment of BPH and is now recommended by American Urologic Association.
Surgical Treatment
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
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
Diagnosis:
Ultrasonography (transrectal) Tumor Marker PSA Biopsy - TURP None of these methods can reliably detect small cancers.
Prognosis of Adenocarcinoma:
Hematuria.
Spread to Lungs or liver rare.