BPH

1. Dr. Saba Khan
House Officer
Dept. of General Surgery & Urology
B & B Hospital

2. CASE
 80 years old presented with the c/o frequency, urgency,
hesitancy, poor flow of urine, feeling of incomplete
voiding, dribbling of urine.
 No h/o fever, burning micturition, dysuria, or
hematuria, or abdominal pain.
 K/C/O HTN and BPH. Drug history- on Cardace,
Isosorbide, Verapamil, Aspirin.

3. O/E:
General Examination Findings:
 GC fair, Dehydration (+), Jaundice (-), Anaemia (-),
Oedema (-), Vitals WNL
 Chest/CVS- NAD
 PA- soft, non tender, non distended
Investigations:
 CBC, URINE RME, LFT, KFT- WNL ( except Na- 129)
Imp: Benign Prostate Hyperplasia
Plan- TURP
Pre-op: due to hyponatremia, operation was withheld
for 2 days. Aspirin was kept on hold.
Relevant OT findings: ~100 gms of prostate was
resected

4. Intra-operative period: uneventful
Post-op period:
 Pt developed retention of urine after few hrs of surgery.
Bladder was washed out and clots were removed.
 On 4th post op day pt again developed retention. Bladder
was washed out and clots removed.
 After 7th post-op day pt’s Foley was removed and he
developed urinary incontinence. Retention on 8th post op
day.
 Foley catheter was placed and removed again on 10th
postop day .
 Patient was discharged on 13th post-op day with
indwelling catheter.

5.  Pt was readmitted after 1 week with indwelling
catheter for observation for 1 day.
 Pt was passing adequate urine, so Foley was removed
and pt was discharged with oral antibiotics and anti-
spasmodic.

6. The Prostate Gland
Clip
 Fibromusculoglandular
organ
 Pear-shaped,wt7-18gm
 ~ 3cm long, sorrounds
prostatic urethra.
 Resembles the size and
shape of a chestnut.
 Helps control urine flow
 Produces fluid
component of semen
 Secretes Prostate
Specific Antigen (PSA)

7. Four Areas of the Prostate
 Transition Zone
 Peripheral Zone
 Anterior Zone
 Central Zone

8. Prostatic capsules
 Normally two but, pathologically three.
 The True Capsule: a thin fibrous sheath that sorrounds the
prostate
 The False Capsule: lies outside the true capsule, formed by
the condensation of pelvic fascia. It continues with the
fascia of Denonvilliers posteriorly and into the fascia
sorrounding the bladder.
 Between true and false capsule lies the prostatic venous
plexus.
 The Pathological Capsule: when BPH takes place the, the
normal peripheral parts of the gland becomes compressed
into a capsule around this enlarging mass. Also called the
Surgical Capsule of the prostate

9. Blood supply
Arterial:
Mainly from the inferior vesical and middle rectal
branches of the internal iliac artery.
Venous :
 To the prostatic venous plexus which, drains into the
internal iliac vein.
 Some venous blood from prostate passes directly to the
valveless prevertebral venous plexus.

10. What is Benign Prostatic Hyperplasia?
A condition in which the prostate gland becomes
enlarged.
Epidemiology:
Occurs in men over 50
years of age; by the age of
60 years, 50% of men
have histological
evidence of BPH.
Peripheral zone
Transition zone
Urethra

11. Etiology
Multifactorial & endocrine controlled:
 Stromal and epithelial elements of the prostate can
give rise to hyperplastic nodules and the symptoms
a/w BPH.
 The association between aging and BPH might result
from the increased estrogen levels with advancing
age, causing induction of the androgen receptor,
which thereby sensitizes the prostate to free
testosterone.

12. Pathology
Develops in the TZ, forming a nodular
enlargement which, compresses the PZ glands
into a false capsule giving the appearance of
typical ‘lateral’ lobes.
When BPH affects the subcervical CZ glands, the
‘middle’ lobe develops that projects up into the
bladder within the internal sphincter.

13. Clinical features
Initially outlet obstruction:
 Weak stream, hesitancy, intermittency, dribbling,
straining to void, acute urinary retention.
Subsequent detrusor instability:
 Frequency, urgency, nocturia, dysuria, urge incontinence.
Finally detrusor failure and chronic retention:
 Palpable (or percussible) bladder, overflow incontinence.
 Enlarged smooth prostate on digital rectal examination.

14. What’s LUTS?
Voiding:
 Hesitancy
 Intermittent stream
 Poor flow (unimproved by
straining)
 Dribbling (including after
micturition)
 Sensation of poor bladder
emptying
 Episodes of near retention
Storage:
 Urgency
 Frequency
 Nocturia
 Urge incontinence
 Nocturnal incontinence
(enuresis)
LUTS is not specific to BPH – not everyone with LUTS has
BPH and not everyone with BPH has LUTS

15. Assessment of patients with LUTS
– International Prostate Symptom Score (IPSS) is based on a survey and
questionnaire developed by the American Urological Association
(AUA).
– It contains:
• seven questions about the severity of symptoms
• Completion gives total score of 35
 1 – 7 mild
 8 – 19 moderate
 20 – 35 severe
– Ask 7 questions. Answers on scale 0 – 5 depending on severity of symptoms
– For first 6 questions scores are
• Not at all = 0
• < 1 in 5 = 1
• < half the time = 2
• About half the time = 3
• > half the time = 4
• Almost always = 5
– Q7
• Never = 0, once = 1, 2x = 2, 3x = 3, 4x = 4, 5x = 5

16. Questions
In past month how often have you
1. Had sensation of not emptying bladder completely?
2. Had urge to urinate in < 2 hours after previous micturition?
3. Found you stopped and started again several times
4. Found it difficult to postpone urination?
5. Had a weak stream (compared to when aged 30)?
6. Had to strain to begin urination?
7. How many times do you get out of bed per night to urinate?
Quality of life
• If you were to spend the rest of your life with your urinary condition just the way it
is now, how would you feel about that?
– Delighted 0
– Pleased 1
– Mostly satisfied 2
– Mixed feelings 3
– Mostly dissatisfied 4
– Unhappy 5
– Terrible 6

17. Investigations
Further investigations
 Voiding diary.
 Ultrasonography of kidneys and
bladder: structural abnormalities.
 Transrectal ultrasound: to
determine prostate size.
 IVU: structural abnormalities.
 Cystoscopy.
 Uroflowmetry and residual
volume measurement
(normal<100 ml): evidence of
obstruction.
Basic investigations
•Urinalysis and urine
culture for evidence of
infection or haematuria.
•FBC: infection.
•U+E and serum creatinine:
renal function.
•PSA: suspicion of
underlying malignancy.

18. Treatment
Mild symptom score (0-7): Watchful waiting with fluid restriction
and reduction in caffeine intake.
Strong indications for treatment (usually prostatectomy )
include:
 Acute retention in fit men with no other cause for retention
 Chronic retention or renal impairment- residual urine of 200 ml
or more, increased BUN, hydroureter or hydronephrosis.
 Complications of BOO- stone, infection and diverticulum
formation.
 Hemorrhage – occasionally, from ruptured vein overlying the
prostate.
 Elective prostatectomy for severe symptoms- a low maximum flow
rate (<10 ml/sec) and increased residual volume (100-250 ml)

19. Medical
α-Adrenergic blockers
 Relax the muscle of the prostate and bladder neck, which
allows urine to flow more easily.
 There are at least five medications in this category: terazosin,
doxazosin, tamsulosin, alfuzosin, and silodosin.
 usually recommended as a first-line treatment for men with
mild to moderate symptoms.
 Side effects — The most important side effects of alpha
blockers are dizziness and low blood pressure after sitting or
standing up. Terazosin and doxazosin are usually taken at
bedtime (to reduce lightheadedness). The dose can be
increased over time if needed

20. 5 α- Reductase Inhibitor:
 inhibit the conversion of testosterone to DHT (most
active form of androgen).
 These drugs, when taken for 1 year, result in a
25%shrinkage of prostate (20% improvement in
symptom score)
 Finasteride and dutasteride
 Side effects — A small percentage of men who take
alpha-reductase inhibitors have decreased sex drive or
difficulty with erection or ejaculation. This side effect is
reversed when the drug is stopped

21. Surgical
Conventional:
 Transurethral resection of prostate (TURP)–
improves max flow rates from 9 – 18 ml/sec and 75%
improvement in the symptom scores.
 Transurethral incision of prostate (TUIP)- men
with moderate to severe symptoms and a small
prostate often have posterior commissure hypreplasia(
elevated bladder neck. Such pt. benefit from TUIP.
 Open simple prostatectomy- if large gland (>100
gms); may be a simple suprapubic prostatectomy
(transvesically) or, a simple retropubic prostatectomy.

22. Minimally invasive therapy:
 Laser therapy- 2 main energy sources, Nd:YAG and
Holmium:YAG
Advantages-
Minimal blood loss
Rare instances of TUR syndrome
Ability to treat pts. on anticoagulants
Disadvantages-
Lack of availability of tissue for pathologic
examination
Longer post-op catherization time
High cost

23.  Transurethral electrovaporization of the prostate
 Microwave hyperthermia
 Transurethral needle ablation of the prostate
 High-intensity focused ultrasound
 Intraurethral stents
 Transurethral dilatation of the prostate

24. Transurethral Resection of
Prostate
 Symptom score and flow
rate improvement with
TURP is superior to that
of any minimally invasive
therapy.
 Risks of TURP include:
 Retrograde
ejaculation (75%)
 Impotence (5-10%)
 Incontinence (1%)

25. Complications of TURP
Intraoperative:
 Hemorrhage- Arterial bleeding can be more pronounced in
casesof preoperative infection or urinary retention because of
a congested gland. Anti-androgen pretreatment with
finasteride or flutamide may reduce bleeding. Venous
bleeding generally occurs because of capsular perforation
and venous sinusoid openings. The amount of intraoperative
bleeding may depend on gland size and resection weight.
 Perforation of bladder or prostatic capsule
 TUR syndrome

26. Post-operative:
 Secondary hemorrhage after discharge of pt.(if clot retention
occurs, catheterization and bladder wash needed; might need re-
admission).
 Bladder tamponade- Recurrent or persistent bleeding sometimes
results in clot formations and a bladder tamponade that require
evacuation or even reintervention (1.3–5%)
 Incontinence- inevitable if external sphincter mechanism is
damaged (when resection extends beyond verumonteum).
 TUR syndrome
 Sepsis- in case of prolonged catheterization or chronic retention,
 Retrograde ejaculation (>75%) and impotence.
 Urinary retention (3–9%)- is mainly attributed to primary
detrusor failure rather than to incomplete resection
 Urethral stricture
 Bladder neck contracture
 Reoperation (recurrence 15-18% after 8 yrs)

27. Irrigation fluid
 The irrigating fluids used in TURP are Glycine,
distilled water, normal saline, mannitol, sorbitol etc.
 However, 1.5% isotonic glycine is used for irrigation
nowadays, to prevent the risk of hyponatremia.
 Post-operatively, irrigation of bladder is done with
sterile saline by means of a 3-way Foley catheter for 24
hour or so.

28. TUR syndrome (water intoxication):
 Caused by early perforation of capsular veins or sinuses,
with consecutive influx of hypotonic irrigating fluid
resulting in hyervolemic, hyponatremic state.
 Clinical manifestations- nausea, vomiting, confusion,
hypertension, bradycardia, and visual disturbances.
 The risk of TUR syndrome increases with resection time
over 90 mins.
 Diagnosis: immediate serum Na level post-operatively
 Treatment- Diuresis, hypertonic saline infusion (if severe
hyponatremia)
 Untreated, TUR syndrome may have severe
 consequences like cerebral or bronchial edema

29. Urethral stricture
 Arise either inside the meatus or in the bulbar urethra
 May be secondary to prolonged catheterization, use of
large catheter, clumsy instrumentation, or the
presence of resectoscope in the urethra for too long.
 An early stricture can be managed by simple
bouginage.
 Later, may be necessary to cut the densely fibrotic
sticture with the optical urethrotome.
 It’s incidence can be reduced by the routine use of Otis
urethrotomy prior to TURP.

30. Bladder neck contracture
 A dense fibrotic stenosis of the bladder neck occurs
following overaggressive resection of a small prostate.
 May be due to the overuse of coagulation diathermy.
 Transurethral resection of the scar tissue is necessary.

31. Associated morbidity and mortality
 Despite the increasing mean age (55% of patients are
older than 70), the associated morbidity of TURP
maintained a similar low level <1% with a mortality
rate of 0–0.25% in large series.
 This might be mainly attributable to the advances in
anesthesia and to the technical improvements of
TURP

32. Conservative management of postoperative
incontinence

33. Acute urinary retention before TURP

34. Thank You !