2. Moderators:
Professors:
◼ Prof. Dr. G. Sivasankar, M.S., M.Ch.,
◼ Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
◼ Dr. J. Sivabalan, M.S., M.Ch.,
◼ Dr. R. Bhargavi, M.S., M.Ch.,
◼ Dr. S. Raju, M.S., M.Ch.,
◼ Dr. K. Muthurathinam, M.S., M.Ch.,
◼ Dr. D. Tamilselvan, M.S., M.Ch.,
◼ Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC,
Chennai. 2
4. B O O
◼ CAUSES
B P H—BENIGN PROSTATIC HYPERTROPHY
CARCINOMA PROSTATE
BLADDER NECK STENOSIS
BLADDER NECK HYPERTROPHY
URETHRAL STRICTURES
STONE DISEASE
4
Dept of Urology, GRH and KMC,
Chennai.
5. Primary effects of BOO
( on the bladder)
• Urinary flow rates decrease
[for a voided volume >200 ml ;
a peak flow rate of
>15 ml/sec is normal
10—15 ml/sec equivocal
<10 ml/sec low
• Voiding pressures increase
>80 cmH2O are high
60 to 80 cmH2O are equivocal
<60 cmH2O are normal 5
Dept of Urology, GRH and KMC,
Chennai.
6. Long term effects of B O O
The bladder may decompensate
• Detrusor contraction becomes progressively
less efficient
• Residual urine develops.
The bladder may become more irritable
during filling with a decrease in functional
capacity partly caused by detrusor instability
6
Dept of Urology, GRH and KMC,
Chennai.
7. BPH
• A non-malignant condition associated with
aging
• Hyperplasia begins in 3rd decade but
symptoms don’t usually occur until
6th decade
• 90% of men 70-90yrs have BPH symptoms
• Risk of severe BPH increases with age 7
Dept of Urology, GRH and KMC,
Chennai.
8. Etiology
Fibro adenomatous nodules in periurethral
region of prostate
Possible triggers are
◼ Binding of androgen receptors in prostrate stroma
Stimulates protein synthesis and prostate
glandular growth
◼ Reversal of estrogen-testosterone balance
with aging
◼ Development of autoantibodies to PSA
◼ Diminished sex life and few ejaculations
8
Dept of Urology, GRH and KMC,
Chennai.
9. Early Symptoms
• Symptoms of mechanical obstruction
– Difficulty in starting stream
– Weak stream
– Post void dribbling
– Sensation of incomplete emptying
– Overflow incontinence
• Early irritative symptom
– Frequency & urgency
– Urge incontinence
– Nocturia
– Painful urination 9
Dept of Urology, GRH and KMC,
Chennai.
10. A- MIDDLE LOBE ENLARGEMENT
B- LATERAL LOBE ENLARGEMENT
C- BOTH MIDDLE AND LATERAL
LOBE ENLARGEMENT
D- POSTERIOR COMMISURAL
HYPERPLASIA
10
Dept of Urology, GRH and KMC,
Chennai.
11. Complications
• Urinary retention
• Uremia
• Irreversible bladder dysfunction
• Hydronephrosis
• Hematuria
• UTI and stone formation
11
Dept of Urology, GRH and KMC,
Chennai.
13. Diagnosis
General physical examination
may demonstrate signs of CRF
anaemia and dehydration.
Abdominal examination
usually normal.
In patients with acute retention,
a distended bladder
External urinary meatus should be examined
to exclude stenosis
13
Dept of Urology, GRH and KMC,
Chennai.
14. DRE – DIGITAL RECTAL EXAMINATION
Prostate feels larger and harder than normal
The rectal mucosa can be made to move over
the prostate
Enlargement not necessary for diagnosing BPH
14
Dept of Urology, GRH and KMC,
Chennai.
15. • LABARATORY TESTS
ROUTINE URINE ANALYSIS
URINE CULTURE AND SENSITIVITY
RENAL FUNCTION TESTS –
BUN, SR. CREATININE , SR. ELECTROLYTES
SERUM PROSTATE SPECIFIC ANTIGEN
HARD, IRREGULARITY/ NODULES
( TO R/O CARCINOMA )
UROFLOW STUDIES
TO KNOW URINARY FLOW RATE 15
Dept of Urology, GRH and KMC,
Chennai.
16. URODYNAMIC PRESSURE – FLOW STUDIES
• men with suspected neuropathy
• men with a dominant history of irritative symptoms
• men with life-long urgency and frequency
• men with a doubtful history and those with flow
rates in the near-normal range (= or >15
mL/second)
• men with invalid flow rate measurements
(because of low voided volumes)
16
Dept of Urology, GRH and KMC,
Chennai.
17. Cysto urethroscopy
Inspection of the urethra, the prostate and the
urothelium of the bladder
Should always be done immediately prior to
prostatectomy, whether it is being done
transurethrally or by the open route
To exclude a urethral stricture, a bladder carcinoma
and the occasional non opaque vesical calculus.
The decision whether to perform prostatectomy must
be made before cystoscopy. This should be based on
the patient’s symptoms, signs and investigations.
17
Dept of Urology, GRH and KMC,
Chennai.
18. DIFFERENTIAL DIAGNOSIS
◼ Rule out other causes of prostate Enlargement
– Prostatitis
– Prostate cancer
– Prostatic calculi
– Venereal disease
◼ Rule out other causes of dysuria
– Urethral stricture
– Bladder neck contracture
– Neurogenic bladder
– Inflammatory Disorder
_ Interstitial cystitis
18
Dept of Urology, GRH and KMC,
Chennai.
19. Medical Treatment
• If there is no evidence of complications
measure severity of disease with AUA symptom
score index
• AUA score
Mild </=7
Moderate 8-19
Severe 20-35
• If mild and pt wants no treatment
Monitor annually
Encourage lifestyle changes
19
Dept of Urology, GRH and KMC,
Chennai.
20. Medical Intervention
◼ First line of treatment for men >60 and
AUA score 8-19
◼ 3 classes of medication available
Anti androgens – 5 @ reductase inhibitors
Long-acting selective α1-blockers
Muscarinic receptor antagonists
20
Dept of Urology, GRH and KMC,
Chennai.
21. Anti androgens
◼ Slows rate of prostate enlargement by
regulating amount of available androgen
Finasteride most commonly used
Prescribed at 5mg/day
Reduces prostate volume and PSA after 3-6
months of therapy
40% no response rate
To screen for prostate Ca –PSA doubling value21
Dept of Urology, GRH and KMC,
Chennai.
22. Selective Alpha 1-blockers
◼ Alpha adrenergic receptors found at bladder neck
and prostate
• Alpha blockers relax smooth muscle in prostate and
bladder neck without affecting bladder contractility
• onset of action takes 2 weeks
• 93% response rate
• 44% mean improvement in urinary flow
• Tolerance to therapy develops
• Caution:
Orthostatic hypotention with
Doxazosin and Terazosin , not Tamulosin
22
Dept of Urology, GRH and KMC,
Chennai.
23. Muscarinic Receptor Antagonists
◼ Effective alone or in combination with
alpha blockers
• Symptomatic relief of frequency, urgency
or urge incontinence in pts with normal renal
function
• Careful with narrow angle glaucoma,impaired
liver function or in presence of anti-fungals or
macrolides
23
Dept of Urology, GRH and KMC,
Chennai.
24. surgical treatment
Strong indications
1.Acute retention in fit men with no other cause for retention
2.Chronic retention and renal impairment:
• residual urine of 200 ml or more
• raised blood urea,
• hydroureter or hydronephrosis ( on urography )
• uraemic manifestations
3. Complications of bladder outflow obstruction:
stone, infection and diverticulum formation
4. Haemorrhage: occasionally, venous bleeding from a
ruptured vein overlying the prostate will require prostatectomy
to be performed
5. Elective prostatectomy for severe symptoms of ‘prostatism’
24
Dept of Urology, GRH and KMC,
Chennai.
25. Conventional operative treatment
This includes:
• Transurethral resection of the prostate (TURP)
• Bladder neck incision for the small prostate (<20 g)
• Open prostatectomy for the big gland (>80—100 g).
25
Dept of Urology, GRH and KMC,
Chennai.
26. Methods of performing
prostatectomy
The prostate can be approached
(1) Transurethrally — TURP
(2) Retropubically — RPP ( MILLIN )
(3) Transvesical — TVP ( FREYER’S )
(4) from the perineum ( YOUNG )
now abandoned 26
Dept of Urology, GRH and KMC,
Chennai.
30. Newer modalities
◼ Minimally invasive methods
These are new and their roles are not yet
determined:
◼ Contact laser of the prostate– KTP , HOLEP
◼ Microwave treatment of prostate
(thermo therapy)
◼ High—energy ultrasound.
30
Dept of Urology, GRH and KMC,
Chennai.
31. Alternative Therapies
◼ Saw Palmetto
– Reduces 5α reductase activity
– 160 mg po bid decreases lower urinary
tract symptoms in double blind studies
• Pygeum africanum palm tree bark
– Contains 3 anti-inflammatory sterols
31
Dept of Urology, GRH and KMC,
Chennai.
33. Disease Definition
◼ Prostate cancer is a malignant tumour of
the prostate
◼ Most common cancer in men in Western
countries
◼ Aetiology of the disease is not well known
33
Dept of Urology, GRH and KMC,
Chennai.
34. Younger men who develop prostate cancer have
a positive family history
Carcinoma of the prostate usually originates in
the peripheral zone of the prostate
34
Dept of Urology, GRH and KMC,
Chennai.
35. Types of prostate cancer
Microscopic latent cancer found on
autopsy or at cystoprostatectomy
Tumours found incidentally during TURP
(T1a and T1b)
or
following screening by PSA measurement (T1c)
•Early, localised prostate cancer (T2)
35
Dept of Urology, GRH and KMC,
Chennai.
36. • Advanced local prostate cancer (T3 and T4)
• Metastatic disease
which may arise from a clinically evident tumour
(T2, T3 or T4)
or
which may arise from an apparently benign gland
(T0, T1), i.e. occult prostate cancer
Only the last two groups cause symptoms and such
tumours are not curable.
Only screening or the treatment of incidentally found
tumours can result in cure of the disease.
36
Dept of Urology, GRH and KMC,
Chennai.
37. Clinical features
Only advanced cases give rise to symptoms, but even
advanced cases may be asymptomatic.
Symptoms of advanced disease include:
• BOO
• pelvic pain and haematuria;
• bone pain, malaise, ‘arthritis’, anaemia
or pancytopaenia
• renal failure
Early prostate cancer is asymptomatic and it
may be found:
• incidentally following TURP for clinically
benign disease (T1);
• as a nodule (T2) on rectal examination. 37
Dept of Urology, GRH and KMC,
Chennai.
38. Histology
Histological pattern is one of an adenocarcinoma.
The first change is
Loss of the basement membrane with glands
appearing to be in confluence.
Gleason Grading
A classification of the histological pattern based on
the degree of glandular de differentiation and its
relation to stroma
Correlate well with the likelihood of spread and
of prognosis.
38
Dept of Urology, GRH and KMC,
Chennai.
39. Digital Rectal examination (DRE)
Irregular induration, characteristically stony hard in
part or in the whole of the gland with obliteration of
the median sulcus
Extension beyond the capsule up into the bladder
base and vesicles is diagnostic, as is deformity and
projection outwards of the capsule
DIAGNOSIS
39
Dept of Urology, GRH and KMC,
Chennai.
40. General blood tests
In early disease : NORMAL
In metastatic disease
•Leucoerythroblastic anaemia secondary to extensive
marrow invasion
•Anaemia may be secondary to renal failure. There may
be thrombocytopenia
•Evidence of disseminated intravascular coagulopathy
with increased fibrinogen degradation products (FDPs)
Liver function tests
The alkaline phosphatase may be raised from either
hepatic involvement or secondaries in the bone.
40
Dept of Urology, GRH and KMC,
Chennai.
41. Prostate-specific antigen
It is lacking in sensitivity and specificity in the
diagnosis of early localised prostate cancer.
Finding of a
PSA > 10 nmol/ml is suggestive of cancer
PSA > 35 ng/mI is diagnostic of advanced
prostate cancer.
A decrease of PSA to the normal range
following hormonal ablation is a good prognostic
sign
41
Dept of Urology, GRH and KMC,
Chennai.
42. Radiological examination
CXR → metastases either in the lung fields or the ribs
Abdominal X-ray
may show the characteristic sclerotic metastases in
lumbar vertebrae and pelvic bones
The bone appears dense and coarse
Osteolytic metastases nevertheless are very common
may coexist with sclerotic ones.
42
Dept of Urology, GRH and KMC,
Chennai.
43. Early detection helps
◼ Survival rate at 5 years is 99% for
those whose cancer is still just in
the prostate gland (localized).
◼ Survival rate at 5 years for those
whose cancer has spread beyond
the gland (late diagnosis) is only
31%
43
Dept of Urology, GRH and KMC,
Chennai.
44. When do need to start getting tested?
⚫ DRE: 40 years and older every year
⚫ (American Cancer Society guidelines)
⚫ PSA: 50 years and older every year
(American Cancer Society guidelines)
⚫ 45 years and older every year
(If family history of prostate cancer and/or African-
American )
44
Dept of Urology, GRH and KMC,
Chennai.
45. TRANS RECTAL Ultrasonography ( TRUS )
•Remains the most accurate method of staging the
local disease.
• It can be used in the early detection of tumours in
screening programmes.
•TRUS plus rectal examination and measurement of
PSA will detect only 30—50 per cent of cancers that
are known to be present on autopsy studies
•Transrectal biopsy done using an automated gun
with appropriate antibiotic cover
45
Dept of Urology, GRH and KMC,
Chennai.
47. Bone scan
As a part of the staging procedure if the PSA is
>20 nmol/ml.
If the PSA is <20 nmol/ml then a bone scan
would only be performed on clinical indications.
Performed by the injection of technetium-99m,
which is then monitored using a gamma
camera.
It is more sensitive in the diagnosis of
metastases than a skeletal survey 47
Dept of Urology, GRH and KMC,
Chennai.
48. TREATMENT
◼ Local disease – Radical prostatectomy
◼ Radical radiotherapy to the prostatic bed and
pelvic lymph nodes rather than radical surgery
( In UK for locally confined prostate cancer)
◼ Advanced disease
Hormonal:
antiandrogen- 5 alfa reductase inhibitor
LHRH analogues
Androgen receptor blockers
Castration 48
Dept of Urology, GRH and KMC,
Chennai.
51. Congenital Narrowings of the Urethra
Congenital urethral stricture
Rare. Some are associated with duplication of the urethra.
Usually symptoms are delayed until adolescence
Single treatment by optical urethrotomy or dilatation
is usually effective
Congenital valves of the urethra
Posterior urethral valve
Anterior urethral valve
(rare associated with proximal diverticula or dilation)
51
Dept of Urology, GRH and KMC,
Chennai.
52. POSTERIOR URETHRAL VALVE ( PUV )
Symmetrical folds of urothelium which can cause
obstruction to the urethra of boys.
Usually found just distal to the verumontanum but they
may be within the prostatic urethra.
Behave as flap valves so, although urine does not flow
normally, a urethral catheter can be passed easily
The valves are difficult to see on urethroscopy because
the flow of irrigant sweeps them into the open position.
52
Dept of Urology, GRH and KMC,
Chennai.
53. Dilatation of the urethra above the valves can be
demonstrated on a voiding cystogram
Treatment
A suprapubic catheter is inserted to relieve the
back pressure
Definitive treatment :
Transurethral resection of the valves using a
paediatric resectoscope
53
Dept of Urology, GRH and KMC,
Chennai.
55. STRICTURE -- Acquired types
Inflammatory
Rare cause of stricture today
Gonococcal urethritis ; Rarely NSU is a cause
Unknown inflammatory conditions such as
Balanitis xerotica obliterans
55
Dept of Urology, GRH and KMC,
Chennai.
56. Traumatic stricture
Pelvic fracture → Membranous urethra
Straddle injuries → Bulbar stricture
Instrumentation catheter, dilators,
cystoscopy or TUR procedures → mainly
Anterior urethra
56
Dept of Urology, GRH and KMC,
Chennai.
57. Pathophysiological Changes
Restriction of flow
Dilation of proximal urethra Turbulence effect
Detrusor hypertrophy
High residual urine
High IVP
Decompensation of UVJ
Reflux
Hydronephrosis
57
Dept of Urology, GRH and KMC,
Chennai.
58. Symptomatology
Decreased stream
Spraying or double stream.
Postvoid dribbling
Chronic Urethral discharge might be noted
Recurrent cystitis, prostatitis or epididymitis.
Retention is rare in severe cases.
Mild dysuria might be initial presentation.
58
Dept of Urology, GRH and KMC,
Chennai.
59. Signs
◼ Induration of the strictured part.
◼ Tender enlarged periurethral abscesses.
◼ Urethrocutanous fistula
◼ Palpable bladder
◼ Fullness of urethra during voiding in
diverticuli.
59
Dept of Urology, GRH and KMC,
Chennai.
60. Laboratory work-up
Measuring flow rate(normal is> 20 mL/s)
Urine culture and sensitivity
Prostatic massage for culture and
sensitivity testing
Serum creatinine and blood urea
60
Dept of Urology, GRH and KMC,
Chennai.
61. Radiological investigations
Ultrasonography is useful for measuring residual urine.
Voiding cystourethrography ( MCU )
Retrograde urethrography ( AUG )
Transurethral ultrasonogram : newer modality
Urethroscopy & urethrocystoscopy
Direct visualization of strictures
Aids in determining the extent, location, and degree
of scarring.
61
Dept of Urology, GRH and KMC,
Chennai.
62. Stricture of urethra
◼ Anterior stricture
◼ Bulbar stricture
62
Dept of Urology, GRH and KMC,
Chennai.
65. Urethrocutaneous fistula
◼ As a complication of
strictured urethra in a
male with chronic
Gon.urethritis
◼ Periurethral abscess
opened into the
scrotum
65
Dept of Urology, GRH and KMC,
Chennai.
66. Treatment
• Dilation should be avoided
• The gold standard is Optical Urethrotomy
• Surgical reconstructive procedures using
skin graft.
• Transpubic or perineal approach might
be required.
• Laser urethrotomy did not add much to optical
urethrotomy procedure 66
Dept of Urology, GRH and KMC,
Chennai.
68. Bladder Stones
Can contribute to recurrent bladder infections
Can block the catheter’s drainage
Should be suspected if “sand” or small stones
are noted on the catheter when it is changed
68
Dept of Urology, GRH and KMC,
Chennai.
69. Treatment
◼ <2 cm – vesicolithotripsy
◼ > 2cm- vesicolithotomy
69
Dept of Urology, GRH and KMC,
Chennai.
