Presentasi Kasus

IDENTITAS PASIEN
Nama : Tn. T Jenis kelamin : Laki-laki Usia : 67 tahun Alamat : Tegal anak RT 03/05 Kedungrejo Cilacap Status pernikahan : menikah Nomor RM : 921.953 Tanggal periksa : 14 Maret 2012

KELUHAN UTAMA
Gangguan buang air kecil

RIWAYAT PENYAKIT SEKARANG

3 HSMRS: os mengeluhkan tidak bisa BAK, ketika ingin BAK, BAK yang keluar hanya berupa tetesan. Urine yang keluar berwarna jernih kekuning2an. Tidak ada keluhan BAK. Pada malam hari sering terbangun malam hari karena ingin buang air kecil hingga lebih dari 2 kali. 1 HSMRS : keluhan os sejak 3 hari tetap disertai dengan nyeri perut bagian bawah.

RIWAYAT PENYAKIT DAHULU

Belum pernah mengalami keluhan seperti ini. Riwayat sakit batu pada saluran kemih disangkal. Riwayat buang air kecil berdarah (-)

RIWAYAT PENYAKIT KELUARGA

Hipertensi (-). DM (-) Riwayat pada keluarga (+) pada saudara kandung dengan keluhan yang sama dan sudah dioperasi.

IPSS SCORE
Incomplete emptying 5 Frequency (BAK setiap 2 jam) 5 Intermittency 5 Urgency 5 Weak stream 5 Straining 5 Nocturia 5

Quality of live 6 (terrible)

RESUME ANAMNESIS
Gangguan buang air kecil, urin yang keluar berupa tetesan. Nyeri perut terutama kanan bawah. Semakin lama tidak bisa buang air kecil. Riwayat keluhan serupa pada saudara kandung.

IPSS score 35

PEMERIKSAAN FISIK
KU : baik Kesadaran : CM VS: TD= 130/90mmHg, HR =72 x/m, RR=20x/m, t: afebris

 Kepala : conjunctiva anemis -/ Leher : lnn ttb, JVP tidak meningkat

Thorax : simetris, sonor pada perkusi +/+, vesicular +/+

Jantung: S1 S2 tunggal, bising -/-. Abdomen : datar, BU+ N, 10x/menit, timpani +/+ Ekstremitas : pucat (-), edema (-)

STATUS LOKALIS UROLOGIS

Flank region : masa -/-, nyeri tekan -/-, nyeri ketok /-, Supra pubik : distended (+), nyeri tekan (+) OUE : discharge -, lesi kulit -, warna kulit dbn.

RECTAL TOUCHER
TMSA : positif Mukosa licin Ampula recti tidak kolaps Teraba masa 2 ruas jari sekitar jam 12, ujung pool/kutub tidak dapat teraba Darah - , feses -, lendir

ASSESSMENT

Susp. BPH

PLAN
Cek Darah Rutin, Ureum Kreatinin, Asam urat, Gula darah sewaktu Cystography USG Abdomen Pro Prostatectomy Pasang DC

PX PENUNJANG
Darah rutin : Hb 14.3, AL 6.630, AT 338.000 Waktu perdarahan : 5, waktu pembekuan : 10 Faal ginjal : ureum 20, kreatinin 0,9 GDS : 114

DIAGNOSIS

Benign Prostate Hyperplasia

PEMBAHASAN

PROSTATE

n Walnut-shaped

gland that forms part of the male reproductive system n Surrounds the urethra - the tube that carries urine from the bladder out of the body

Prostate
n Secretes

semen which carries sperm

During orgasm, prostate n muscles contract and propel ejaculate out of the penis

BPH

n The size of prostate enlarged microscopically since the age of 40.Half of all men over the age of 60 will develop an enlarged prostate By the time men reach their 70 s and 80 s, 80% will n experience urinary symptoms
But only 25% of men aged 80 will be receiving BPH treatment

BENIGN PROSTATIC HYPERPLASIA

NORMAL PROSTATE ANATOMY

Prostate weights ~20g Measures 3 x 4 x 2 cm (walnut sized) Apex = inferior portion of prostate, continuous with striated sphincter. Base = superior portion and continuous with bladder neck.

PROSTATE HISTOLOGY
Prostatic tissue is formed of two components : fibromuscular tissue (30%)

glandular

epithelial cells (70%)

NORMAL HISTOLOGY OF THE PROSTATE FORMED OF GLANDS AND STROMA GLANDS:

LINED BY TWO LAYERS OF CELLS WHICH ARE INNER CUBOIDAL CELLS AND OUTER BASAL CELLS STROMA :FIBRO MUSCULAR STROMA

PROSTATE ZONES
Central zone (CZ) Cone shaped region that surround the ejaculatory ducts (extends from bladder base to the verumontanum)
Only

1-5% of prostate cancer from this region .

Peripheral zone (PZ) Posteriolateral prostate Majority of prostatic glandular tissue Origin of up to 70% of prostate adenocarcinoma Transitional zone (TZ) Surrounds the prostatic urethra Commonest site for benign prostatic hyperplasia.

WHAT CAUSES BPH?

n

BPH is part of the natural aging process, like getting gray hair or wearing glasses BPH cannot be prevented

BPH can be treated

n

Half of all men over the age of 60 will develop an enlarged prostate. By the time men reach their 70s and 80s, 80% will experience urinary symptoms
But only 25% of men aged 80 will be receiving BPH treatment

BPH PROPOSED ETIOLOGIES

1-alterations in the testosterone/estrogen balance:enlarged

prostate may be caused by lower levels of testosterone (male hormone) production in middle to old age. As men age, the levels of testosterone in their blood decreases, leaving a higher proportion of estrogen (female hormone), so a higher amount of estrogen within the prostate gland can increase activity that promotes cell growth.

2-Induction of prostatic growth factors. 3- Increased stem cells/decreased stromal cell death

BENIGN PROSTATIC HYPERTROPHY (BPH)PATHOPHYSIOLOGY

Common in older men; varies from mild to severe Change is actually hyperplasia of prostate

Nodules form around urethra

Not change to cancer prostate. Rectal exams reveals enlarged gland Incomplete emptying of bladder leads to infections Continued obstruction leads to distended bladder, dilated ureters, renal damage

If significant, surgery required

WHATS LOWER URINARY TRACT SYMPTOMS SECONDARY TO PROSTATIC URETHRA OBSTRUCTION?

Abnormal 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:an increasingly

strong desire to void)

Frequency Nocturia Urge incontinence

LUTS is not specific to BPH not everyone with LUTS has BPH and not everyone with BPH has LUTS

BPHSIGNS AND SYMPTOMS

Initial signs

Obstruction of urine flow

Hesitancy : delay between trying to urinate and the flow actually beginning.
dribbling decreased force of urine stream Incomplete bladder emptying

Frequency, nocturia : need to urinate at night recurrent Urinary Tract Infections

BPH
COMPLICATIONS

hypertrophy of the prostatedetrussor muscle of the bladder undergo hypertrophy to overcome the obstruction in the prostatic urethra. Later on decompensation occur .

Increase

pressure inside bladder diverticula formation

increasing urine retention hydronephrosis

renal failure.

DIVERTICULA IN

BLADDER

DIAGNOSIS OF BPH
Symptom assessment
Digital rectal examination(DRE) Prostate Volume (PV) determination by ultrasonography Urodynamic analysis Measurement of prostate-specific antigen (PSA)
high correlation between PSA and PV, men with larger prostates have higher PSA levels PSA is a predictor of disease progression and screening tool for Cancer Prostate. as PSA values tend to increase with increasing Prostatic Volume and increasing age, PSA may be used as a prognostic marker for BPH. inaccurate for size but can detect shape and consistency

WHEN SHOULD BPH BE TREATED?

BPH needs to be treated ONLy IF:
n

Symptoms are severe enough to bother the patient and affect his quality of life

Complications related to BPH n

Treatment options
Medication : blockers - relax the smooth muscle of prostate
and provide a larger urethral opening

Surgical approaches
1- Transurethral resection of the prostate (TURP) 2- Open simple prostatectomy

WATCHFUL
n For

WAITING

mild symptoms. follow up1 to 2 times yearly

n Offer

suggestions that help reduce symptoms

nAvoid

caffeine and alcohol nAvoid decongestants and antihistamines

MEDICATION
n First line of defense against bothersome urinary symptoms

Two major types:

n
blockers - relax the smooth muscle of prostate and provide a larger urethral opening n
(Hytrin,Doxaben, Harnalidge)

n5

reductase inhibitor -

Shrink the prostate gland

(Proscar, Avodart)

Medication
Benefits
n Convenient n n

Disadvantages
Drug Interactions Must be taken every day

No loss of work n time Minimal risk

n

Manages the problem n instead of fixing it

POSSIBLE SIDE EFFECTS OF

medication
n
n n

Impotence Dizziness Headaches

n
n

Fatigue
Loss of sexual drive

-ADRENERGIC BLOCKERS: RATIONALE

Prostate smooth muscle tone is mediated via 1-adrenergic receptor Blockage of the receptor leads to improvement of flow rate and LUTS1 Central -receptors and the effect of agents on these receptors likely play an additional role Density of adrenergic receptors changes with prostate size and age

Three 1-adrenergic receptor subtypes have been identified (A, B, D)

Schwinn DA. BJU Int. 2000;86(suppl 2):11-22.

-BLOCKERS Nonselective

Phenoxybenzamine Prazosin, Alfuzosin

Short-acting selective 1-blocker

Long-acting selective 1-blockers
Terazosin Doxazosin

Long-acting selective 1A-subtype

Tamsulosin Alfuzosin-SR

INDICATION OF SURGICAL INTERVENTION Acute urinary retention Gross hematuria Frequent urinary tract infection (UTI) Vesical stone BPH related hydronephrosis or renal function deterioration Obstruction

DIFFERENTIAL DIAGNOSIS OF BPH(I.E FROM OTHER CAUSES OF URINARY OBSTRUCTION)

Urethral stricture Bladder neck contracture Carcinoma of the prostate Carcinoma of the bladder Bladder calculi Urinary tract infection and prostatitis Neurogenic bladder

TURP

(transurethral resection of the prostate)

Standard of care for BPH n Uses an electrical knife to surgically cut and remove excess prostate tissue Effective in relieving symptoms and n restoring urine flow

n Gold

TURP

Gold standard of surgical treatment for BPH 80~90% obstructive symptom improved 30% irritative symptom improved Low mortality rate 0.2%

THE GOLD STANDARDTURP

Benefits
n

Disadvantages
n Greater

Widely available

n
n

Effective
Long lasting
n

risk of side effects and complications

1-4 days hospital stay

1-3 days catheter 4-6 week recovery

n
n

COMPLICATION OF TURP
Immediate

complication

bleeding capsular perforation with fluid extravasation TUR syndrome

Late

complication

urethral stricture bladder neck contracture (BNC) retrograde ejaculation impotence (5-10%) incontinence (0.1%)

OPEN SIMPLE PROSTATECTOMY

too large prostate -- >100 gm Combined with bladder diverticulum or vesical stone surgery Suprapubic or retropubic method

MINIMALLY INVASIVE THERAPY

During the last decade, numerous amounts of minimally invasive therapy modalities have been developed to challenge the traditional surgery of TURP The aim of these therapies is to achieve results similar to TURP but with minimal anesthesia, complication, risk and hospital stay.

MINIMALLY INVASIVE THERAPY FOR BPH

transurethral balloon dilatation of the prostate (TUBDP) transurethral incision of the prostate (TUI) intraprostatic stent transurethral microwave thermotherapy (TUMT) transurethral needle ablation of the prostate (TUNA) transurethral electrovaporization of the prostate (TUVP) photoselective vaporization of the prostate (PVP), Cryotherapy Transurethral ethanol ablation of the prostate (TEAP),

MINIMALLY INVASIVE THERAPY FOR BPH

transurethral laser-induced prostatectomy (TULIP) visual laser ablation of the prostate (VLAP) contact laser prostatectomy (CLP) interstitial laser coagulation of the prostate (ILC) holmium:YAG laser resection of the prostate (HoLRP) holmium:YAG laser enucleation of the prostate (HoLEP) high-intensity focused ultrasound (HIFU) coagulation botulinum toxin-A injection of the prostate

SUMMARY

Minimally invasive therapies for the treatment of BPH has the advantages such as less blood loss, less occurrence of hyponatremia, quicker recovery, and reduced risk of urethral stricture. However, it also has the disadvantages such as longlasting bladder irritation owing to higher temperature during therapy and possible longer catheterization period due to swelling of the prostate. It is still too early to make a definitive conclusion concerning the future role of these minimally invasive therapies for the treatment of BPH.

Thanks for Your Attention!