BPH, Inflammatory diseases of prostate As. Prof. Lukáš Bittner M.D., FEBU Urologická klinika 3. LF UK a FNKV

BPH (Benign Prostatic Hyperplasia) Most common „benign tumor“ in men Prevalence 20% age % age ›90% older than 80

Prevalence of BPH

Etiology BPH Multifactorial Endocrine controlled Positive correlation between levels of fT and E and volume of BPH Increase of E causing induction of androgen receptor, sensitivity

BPH

Pathology of BPH BPH develops in transition zone Hyperplastic process, increase of cell No. Nodular grown pattern of stroma + epithelium Stroma 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 lobes 2 lateral 1 median (impalpable)

Prostate 25y.o.

Prostate 50y.o.

Clinical Findings Obstructive complains Hesitancy* Decreased force and caliber of stream Sensation of incomplete bladder emptying Double voiding Post void dribbling * Difficulty in beginning Irritative complains Urgency Frequency Nocturia =LUTS Low Urinary Tract Syndrom

IPSS score 0-7 Mild 8-19 Moderate Severe

Examination DRE S PSA Urinalysis Post void residuum- USG UFM

Uroflowmetry (UFM)

UFM terminology

UFM findings

Differential Diagnosis Urethral stricture Bladder neck contracture Bladder stone CaP Infection Tumor of bladder

Absolute surgical indication Refractory urinal retention Recurrent urinary tract infection from BPH Gross hematuria from BPH Bladder stones from BPH Renal insufficiency from BPH Large bladder diverticula from BPH

Medical therapyof BPH IPSS mild symptoms- watchful waiting Alpha-blockers 5-alfa reductase inhibitors Phytotherapy

Alpha-blockers Prostate and bladder base contains alpha-1 adrenoreceptors Shows contractile response Fast onset Time limited efficiency Side effects: hypotension, dizziness, headache, retrograde ejaculation Tamsulosin, Alfuzosin- alpha 1a selective, once daily

5-alfa reductase inhibitors Block conversion of T to dihydrotestosteron Affects epithelial component Reduction of size (6monts 20%) PSA is reduced Late onset, long acting Reduced risk of acute retention and need of surgery Side effects: erectile dysfunction, decreased libido, gynekomastia Finasteride, Dutasteride, once daily

Phytotherapy Saw palmeto berry (serenoa repens) Bark of Pygeum africanum No benefit in randomised trials

Surgical therapy Conventional therapy Transurethral resection of prostate (TURP) Open simple prostatectomy Minimal invasive therapy Laser therapy TUNA TUMT Stents

Surgical treatment algorithm

Transurethral resection of Prostate (TURP)

TURP

Pros. Shorter hospital stay Minimal to moderate bleeding Cons. Strictures of urethra 5% of ED TUR 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. Symptoms Confusion nausea and vomiting arterial hypertension Bradycardia pulmonary edema and impaired vision.

TUR Syndrome Risk factors Prostate volume over 45 ml resection time over 90 min height of the irrigation fluid by the patient over 70 cm. Lab controla Sodium level Treatment Furosemide is given (20–40 mg i.v.) hypertonic NaCl solution slowly

Transvesical prostatectomy (TVPE)

TVPE

Pros. Safe for urethra Shorter operation time Cons. Moderate to severe bleeding Longer hospital stay

Acute bacterial prostatitis

Acute prostatitis Associated with UTI ascending urethral infection Reflux of infected urine from bladder Most common urologic Dg. In men ≤50

Presentation Abrupt onset Fever Chills Malaise Back/rectal/perineal pain Urinary sy Frequency Urgency Dysuria

Findings DRE- tender, warm, enlarge gland Urinalysis WBC Serum: leukocytosis, elevation PSA Avoid prostatic massage, urethral catheterization

Causative organisms E. coli Proteus Klebsiella Pseudomonas

Treatment Trimethoprim and fluoroquinolones Good penetration 4-6 weeks If urine retention present- placement of suprapubic catheter

Chronic bacterial prostatitis Present with Dysuria Urgency Frequency Recurrent UTI DRE Often normal PSA may be elevated

4- Cup Test (Stamey) Collect firs 10 mL voided urine (VB1) Discard next 100mL Collect next 10 mL (VB2) Massage prostate and collect prostate expressate (ESP) Collect first 10 ml of voided urine after massage (VB3)

interpretation All specimen ≤10 3 CFU/mL not bacterial prostatitis VB3 of EPS › 10 3 CFU/mL bacterial prostatitis Only VB1 pos.- urethritis ALL positive- treat UTI and repeat Alternative – voided specimen before and after prostatic massage

Treatment of Chronic Prostatitis Trimethoprim and fluoroquinolones Duration of Th 3-4 months Alfa blocker will reduce symtom recurrences