bph [compatibility mode]
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Bladder outlet obstruction & Obstructive
uropathy
BPH
.
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Introduction
• Noncancerous enlargement of the prostate gland• Is a proliferative process of cellular
elements(sromal& epithelial cell proliferation)
• Occurs primarily in transion zone of the prostate
• Increase with age
• Hormonally dependent(testosterone&DHT)
• Not all men with Bph have LUTS or not all men with
LUTS have Bph the same can be said for Boo
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Anatomy
• Wal nut –sized gland
• Part of reproductive system
• Has 3 lobes & 4 zones
• The transion zone surrounds the urethra• Located in front of the rectum ,below the bladder
• Blood supply from inferior vesical.mid
hemorroidal,&internal pudenda
• Venous drain (to pelvic plexus & bastone veins)
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Functions
• Produce alkaline fluid for liquefaction of thesemen ,comprises~ 70% of seminal volume,
provides nutrients for the sperm ,
•Conduit for semen to pass
• Prevent retrograde ejaculation by closing the
bladder neck during sexual climax
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Definition & epidemiology
• Enlargement of the prostate glands due to an
increased number of epithelial & stromal cell
in periurethral area
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Epidemiology
• In U.S.A 14 million have symptoms of BPH
• Worldwide about 30 million
• Common in male older than 50ys
• By age of 60 =60% & by age of 80=90%
• Sexual activity (increase fibro muscular stromal cell)
& increase the risk of BPH• Alcohol( decrease plasma testosterone & increase of
testosterone clearance& decrease the risk of BPH
• Smoking increase testosterone & estrogen level & ithas positive & inductive effect of on development of
BPH
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Etiology
Unknown
Aging
Hormonal effects
Androgen is important for both normal & abnormal growthof the prostate
90% of prostatic androgen is in form of DHT( fromtesticular androgen & 10% from adrenal androgen)
Stromal – epithelial cells interaction produce growthfactors (epidermal GF, insulin like GF,fibroblast GF)
Increased estrogen increase the expression of AR in agingprostate & increase prostate size
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Pathogenesis
(Gland Enlargement)
Occurs as results of increased Number ofepithelial & stromal cell ( increased cellproliferation)
Disruption of equilibrium between cell death
& cell proliferation(decreased in cell death)Androgen requiring during development,
puberty,& aging
Castrated men or no androgen results no BPH
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Common symptoms
(symtomatology)
Prostatism =LUTS
Classified in to irritative
obstructive frequency
Weak urine stream urgency
Difficulty starting urination urge incontinency
Dribbling enuresis
Needing to urinate several times
Straining
Sensation poor bladder emptying
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Symptomatology……
• Scoring system IPSS
AUA
• Used for assessment of symptom severity
• Assess the response to therapy
• Detect symptom progression ( in watchful waiting Rx)• Can not used to establish the DX of BPH(infections,tumor
,bladder disease will have a high ipss)
• According to IPSS – 0-9 mildly symptomatic
– 8-19 moderately symptomatic – 20-35 severely symptomatic
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Effects of BPH
Initially bladder becomes hypertrophiedIncrease postvoidal residuals ,poor
contractility
LUTS & Boo
Urinary retention
Hematuria ,urinary infection
Stone formation ,trabeculation
Bladder irritability ,renal insufficiency
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DDX of BOO
• BPH
• BNC
• Bladder stone
• Urethral stricture
• Prostatic cancer
• Neurogenic bladder
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Diagnosis of BPH
• To pathologist is microscopic Dx(cellular proliferation
of stomal & epithelial elements)
• To radiologist makes the Dx in presence of bladder
neck elevation of cystogram phase of IVP or enlarged
prostate
• To urodynamist -elevated voiding pressure
-low urinary rate
• To practicing urologist is constellation of sign &
symptom
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Diagnosis…..
• Hx – onset of the symptoms
– Age
– Hx of STD
• Determine which symptoms are predominant(
irritative or obstructive)
• Determine severity of the symptoms by IPSS)
• Hx of hematuria ,UTI,diabetis ,NS disease ,urinary
retention, surgery ofLUT
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Diagnosis…..
•
P/E general assessment
(chest,cvs,anemia,external genitalia)
Abdominal examination
Bladder distention
Dullness
Tenderness
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Diagnosis….
• DRE –prostate size,consistance,noduls
-pelvic floor tone flactuance &pain
- prostate size does not correlate with symptomsseverity & degree of urodynamic obstruction & Rx
outcome
• Prostate is large,smooth,convex,elastic,firm,mucosamoves over the prostate
• Ns examination (r/o cavaequina lesions)
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Investigations
U/A –dipstick & /or via centrifuged sediment forblood,bact,prot,glucos …
-cytology for severe irritable symptom
-urine culture
PSA to R/o prostatic Ca which can coexist withBPH
• Large BPH may have slightly elevated PSA
• PSA value >4ng/ml or DRE induration or nodularityneeds transrectal us & multiple biopsy
• PSA & DRE increase the detection rate of prostate Caover DRE alone
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Investigations….
Serum creatinine to R/o renal insufficiency
occurs in 13% of case
BPH with RI increase the risk of post.op. complication
with RI 25%
17% without RI Help to evaluate the pt.with occult & progressive renal
damage secondary to silent prostatism
Postvoidal residual urine
-obtained after voiding of urine with a catheter
transabdominal usNV= less than 5 ml (78%), less than 12ml(100%)
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Investigations….
Pressure flow studies
-done to distinguish b/n low pressure flow rate secondaryto Boo & decompensated bladder
- Reliable if Boo not Dxed by flow rate, initial evaluation & PVR
uroflometry- electrical recording of the urine flow rate
-noninvasive urodynimic test
-quantifies strength of urine stream
-2 to 3 voids with voided volume 150 to 200ml in flow rate
clinic
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Investigations ….
Imaging studies
IVP/US/KUB
-determine bladder & prostate size
-degree of hydronephrosis-not indicated for initial evaluation of LUTS
Indications
- UTI -hematuria -Hx of urolithiasis -Hx of urinary
tract surgery
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Investigations…..
Upper tract imaging is indicatedConcomitant hematuria
Hx of urolithiasis
Elevated creatinine
Increased post voidal residual &Hx of UUTI
UrethroscopyIndications -hematuria -urethral stricture
-bladder Ca -prior LUT surgery
Advantage -prostate enlargement -bladder stone -trabeculation -diverticula's -voidal obstruction of
urethra or bladder neck
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TREATMENT
Aim of Rx
Relieving LUTS
Decreasing Boo
Improving bladder emptying
Reversing renal insufficiency Preventing feature episodes of hematuria ,UTI
&urinary retention
the treatment includesMedical therapy
Minimally invasive
Operative therapy
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Medical therapy
Alpha adrenergic blocker drugsTerazosin(longe acting)
Duxazosin(longe acting)
Tamsulosin(alpha 1a selective)
The tension of prostate smooth muscle is mediatedby alpha1 adrenorecepter
98%of alpha1AR located in prostate
By blocking this receptors
Decrease the resistance a longe bladder neck,
prostate,& urethra( relaxing of smooth muscle)Relieve dynamic component of the obstruction
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Medical therapy
Advantage of alpha adrenergic blockersWell tolerated
Reduce out flow resistance
Are safe in the elderly & Boo
Treatment of choice with pt.HPT
Side effects
Asthenia
Headachedizziness
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Medical therapy
Androgen suppression (5alpha-reductase inhibitor)drugs -finasteride* -flutamide
Is an enzyme responsible to the conversion of thetestosterone to DHT which promotes growth of prostatetissue
Finasteride is competitive inh. Of this enz Lower intraprostatic levels of DHTprostate size
(By inh of its growth ,apoptosis &involution )
Max reduction of prostate vol.by 6/1220% size reduction
1/3 of the pt has improvement of symptom score
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Treatment…. Watchful waiting Rx
For mild symptoms
AUA symptom score<8 flow rate >10ml/s
good bladder emptying(RU<100ml)
-Needs base line evaluation (annually)
Advice for: Limit fluid intakes at evening
↓ alcohol & coffee containing products Maintain time voiding schedules
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Minimally invasive Mx of BPH
Intraprostatic stents
• Tubular device left in the urethra (absorbableor nonabsorbable)
• An alternative for indwelling catheter forpts.unfit for surgery
• Success rate is from 50 to 90%
• The insertion is endoscopicaly(us guided)
• Temporally or permanent( after radical
prostatectomy with incontinence)
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Minimally invasive Mx…
Transurethra microwave therapy
Deliver heat to the prostate via urethra catheter or
transrectal route
Damaging to sympatatic nerve ending & induction ofapoptosis → ↓ prostate size
Takes one hour as out pt with LA
Less complication(like impotence)
Does not cure BPH –reduce urinaryfrequency,urgency,sraing &intermittent flow
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Minimally invasive…..
Lasers delivered heat
Causes destruction of the prostate tissue(coagulation necrosis or vaporization of prostatetissue)
Destroyed tissue then contract→ ↓prostate size
Increase flow rate=9to15ml/sec
Symptoms score improve by 50%
Decrease bleeding ,fluid absorption, length ofhospital stay
↓the incidence of retrograde ejaculaon&impotence compared with TURP
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Minimally invasive….
Transurethral needle ablation of the prostate
Radiofrequencey energy through twin needle
to burn the enlarged prostate
Thermal injury to lateral lobe induce necrosisof hyper plastic prostate &improve symptom
score
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Prostatectomies
Types TURP
RP
TVP
Success AUR & CUR=100%
sever symptoms & urodynamically proven BOO =90%
Mild symptoms =65
Unobstructed detrusor instability =do not respond well
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Prostatectomies….
Pre-op preparation Two unit of blood
Counseling
Obtain consent
Inform the pt about benefit &risk – Retrograde ejaculation
– Erectile dysfunction
– Urinary incontinence – UTI ,BNC ,& urethral stricture
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prostatectomies
TURP
Developed in 1920 & 30s in USA
Used endoscopy (fibroptic lighting together with theHopkins, rod lens wide angle system for visualization
High energy electrical current is used ,entire deviceattached to video camera
Gold standard ( 90% of prostatectomy)
Solution used for TURP →5%DW ,1.5 %glycine ,cystol
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TURP……
Under regional or GA with lithotomy position
Through resectoscope the prostate is
removed
MAX flow rate improve 9 to 18 ml/sec & symptomscore by 70%
Indications -AUR -recurrent infection
-recurrent hematuria -renal insufficiency
-upper urinary tract dilatation
-gland size <40gm*
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Open prostatectomy
Indications Large prostate >80gm with concomitant bladder
stone
Ankylosis of the hip &other orthopedic condition
Sever symptoms unresponsive to medical Rx
All other indications for TURP
Urethra stricture or previous hypospadias repair
Associated inguinal hernia
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Open prostatectomy….
Generalpreparation of 1-2unit of blood
counseling (inform the risks)incontinence
Retrograde ejaculationImpotence
BNC,UTI,Urethral stricture
Needs of blood transfusion
untoward effects(DVT,pul.embolism)
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Open Prostatectomy …. Anesthesia -spinal or epidural (standard)
- GA
the resection could be retro pubic or suprapubic approach
Retro pubic prostatectomy is the enucleation of hyperplasicprostatic adenoma through a direct incision of the anteriorprostatic capsule
Advantage compared with TVP
Anatomical exposure of the prostate
Direct visualization of the prostatic adenoma duringenucleation to ensure complete removal
Visualization of the prostatic fossa after removal to controlbleeding &minimal surgical trauma to uri,bladder
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Open prostatectomy…..
TVP is enucleation of the hyperplasic adenomathrough an extra peritoneal incision of the loweranterior bladder wall
This operation ideally suited pt.with
Large median lobe protruding in to bladder Clinically significant bladder diverticulum
Large bladder calculi
In obese (difficult to access to the prostatic capsule&dorsal vein complex)
Disadvantage( visualization of the apical adenoma is↓ →post. Op. urinary connence)
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Therapeutic optionsIn older men with obvious palpable enlargedprostate or PSA>1.4ng/ml the choice is
Life style change
Alpha blocker &5-alpha reductase inh.
TURP
In younger men with obstructive symptoms ,smallprostate & PSA<1.4ng/ml the choice is
Life style change
Alpha adrenergic blocker
TUIP
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Open prostatectomy….
Contraindications
small fibrous gland
The presence of prostate cancer
Previous prostatectomy Pelvic surgery that obliterate access to the
prostate gland
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Prostatectomy…..
Post-op Mx
Measure output input
Bladder irrigation
Effective pain mx
1st p.o.day fluid diet, ambulation ,deflate balloon(10ml↓)
& irrigate residual clot
2nd p.o.day regular diet
3rd p.o.day remove retro pubic
4th p.o.day discharge with catheter 5- 7 pod day remove catheter
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Prostatectomy…..
Complications
Bleeding -urethral catheter traction with 50ml ofsaline to compress the bladder neck & prostatic fossa
-bladder irrigation to prevent clot formation
-the inflow through urethral catheter &out flowthrough the suprapubic tube
-if the bleeding persist cystoscopic inspection of theprostatic fossa &bladder neck
-if marked bleeding continue to persist →open re-
exploration
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Complications……
Perforation of the bladder & prostatic capsule (INTURP)
Incontinency (if damaged external sphinctermechanism)
Retrograde ejaculetion(80-90%) & impotence (3-6%due to damage of the nerves associated witherection)
Bladder neck contracture
Urethral stricture
SepsisDeath(0.2 to 0.3%)
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Complications….
TUR-syndrome
In 2% of all TURP
Due to absorption irrigating fluid through cut openveins
Characterized by (hyponatremia →↓Na+,HPT,nauesa& vomiting,bradicardia,visualdisturbance,mental confusion)
Risk factors (gland>45gm,↑resecon me >90mnt &
much fluid for irrigation RX diuretics &correct electrolytes
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Urethral stricture
Arise from varies causes
Can occur secondary to inflammation or ischemicprocess leading scar ssue formaon→scar ssuecontract &↓the calibre of urethral lumen→resistance to ante grade flow of urine→common in
male (longer urethral)Anterior urethral stricture is secondary to scaring in
spongy erectile tissue of the corpus spongiosum(more common)
The post. Urethral stricture is due to a fibro tic
process
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Etiology
Inflammatory →post. Gonorrheal
(common),Tbc,schstosomiasis
Traumatic →external injury to pelvis area
Instrumental →longe term use of urethralcatheter or cystoscopy
Post.op →open prostatectomy &utaon
of penis
congenital
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Clinical manifestation
Obstructive voiding symptoms
Decrease force of stream
Incomplete emptying of the bladder
Terminal dribbling
Urinary intermitency
Urinary retention
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Diagnosis
HX (previous op, trauma,STD ,)
P/E (suprapubic & genital area)
Urethroscopy →to detect the degree of
narrowing of the urethraRetrograde urogram →site,degree,number
&length of stricture(failure to pass the
medium beyond the tightness
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Treatment
Accurate diagnosis &assessment of location & lengthof the stricture is important for the Rx
Temporally or short term Rx(pt with acute pain orsever blocking of the urine flow)
• Suprapubic catheter
• Nephrostomy tube (inserted in pt. back to draindirectly from kidney
• Dilation –gradually open the urethra
-used different size buggies
-the goal is to strech the fibrotic tissue withoutproducing more scar
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Treatment ….
Endoscopic internal urethrotomy
For short to medium stricture at the external end ofthe urethra
Under direct vision the stricture is cut open withknife, laser or electrocautory
Release of scared tissue
Leave small catheter for 3-5 days(opose woundcontraction & allow epithelazation)
Success rate→50% permanent cure of simple
stricture
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Treatment …..
Complications
Bleeding
Infection
Recurrence of the stricture
Advantages
Is minimally invasive
More rapid recovery
Minimal scaring
Less risk of infection from surgery
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Treatment …..
Open urethral reconstruction
Most common effective Rx
Used for longer stricture (length 1-2cm)
Extensive mobilization of the corpus sponiosum
Involves complete excision of the fibrotic (stenosed)segment with reanastomosis of the spatulated cutend(tension free & widely patent)
Some times need replacement of strictured urethra(free-fulthicknes or pediculated skin
graft)→myocuyaneous patch of perianal skin &dartus muscle ,bucal mucosa,penile skin
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Treatment ….
Permanent catheter or implant stent
For the pt. who chooses no to undergo
surgery or who has sever stricture
Provide a patent lumenMost successful in short length stricture in the
bulbous urethra
If all else fails →urinary diversion (appendico-vesicostomy
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Complications
Retention of urine
Urethral diverticulum →excision &repair
Periurethral abscess →drain, anbiocs &
suprapubic catheterUrethral fistula
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Bladder calculus
Primary bladder calculus
are developed in sterile urine often originated in
the kidney
pass down to the urether then to bladder &enlarges
Secondary bladder calculi
occurs in presence of infections ,Boo , foreign
body
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Bladder calculi
Composition
Are mixed with one component in excess
Are simple or multiple in number
Uric acid is most common in adults(50%)Ammonium acid urate ,calcium oxalate are
common in pediatric age
Most are mobile with bladder same are fixed
to bladder mucosa (when formed in suture, intumors or retained stents
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Bladder calculi. ….
Risk factors
• Male (8x than female)
• ↑age
•Poor fluid intake
• Incomplete emptying of the bladder
• Recurrent urinary infection
• Foreign body (nonabsorbable suture ,metal
staples,stents & catheter fragments)
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Clinical features
Male 8x than female
Asymptomatic
Frequency →the earliest symptom common during
day time
Sensation of incomplete bladder emptying
Pain ▬at the of micturation
▬referred to the tip of penis & labia majora
aggravated by movs. Screaming & puling the peniswith the hand at the end of urination
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Clinical feature….
Hematuria▬bright red blood at the end of
micturation
Interruption of urinary stream
Pyuria(rare)
Symptoms of urinary infection
P/E
Suprapubic area
Rectal or vaginal exam. (large calculi is palpable infemale
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Investigations
♣ U/A (for blood, pus, crystals typical of calculi)
♣ CBC
♣ plain abdominal x-ray –radiopaque calculus seen
♣US
♣ IVU---filling defect in case of radiolucent calculus
♣ Cystoscopy – to examine the inside of the bladder
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Treatment
♠ Medical Rx
Alkalization of urine for dilution of the uric acid stone
Analgesic
Antibiotics
♠ Surgical Rx --Indications Failed medical Rx
Recurrent infection
Suprapubic pain & AUR
Gross hematuria
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Treatment ….
▲Cystolitholapxy ▬through cystoscope
lithotrite the calculus is broken. fragments are
crushed in to small pieces then removed
▲Suprapubic lithotomy ▬the calculusevacuated through suprapubic incision
▲Suprapubic cystolitholapxy
▲ECSWL
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Bladder neck contracture
Causes Boo
Muscular hypertrophy
Stenosis of the tissue at the neck following
TURP or dense fibrotic stenosis as result ofover use of diathermy (coagulating diathermy)
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Treatment
Alpha adrenergic blocker drugs cause
relaxation bladder neck →→improve urinary
flow
Transurethral incision of the fibrotic tissue ofbladder neck is an operative option
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References
Campbell's Urology 8th edition
Schwartz's Principles of surgery 8th edit
Sabiston Text book of surgery
Internet
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Neurogenic bladder
The lower urinary tract mechanism regulated bybiomechanics of bladder & urethral muscle &controlled by NS
Causes of neurologic bladder dysfunction
Trauma to spinal cord →→disrupts normalsupraspinal circuit that control the urine storage &release
Stroke
Herniated intervertebral disc
Degenerative neurological disease (multiplesclerosis) ,diabetes ,syphilis ,acute infection
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Symptoms
Similar as other causes of LUTS
Diagnosis
Hx →which feature suggesve of an
underlying neurological disease Symptoms & signs
P/E –rectal examinaon (↓perianal sensaon,poor anal sphincter tone & absence of bulb
cavernous reflex ) Lower abdominal exam..
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investigations
U/A CBC RFT
U/S IVP
Urodynamic studies(urine flow rate,cystometry&postvoidal residual)
Complications Urinary leakage & urinary retention
Damage to tiny blood vessels of kidney
Infections of the bladder & urethra
Formation of kidney stone
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Management
Goals
Prevention of upper tract damage
Urinary continence
Effective bladder emptying
Essential to ensure low pressure urine storage
,low pressure voiding &adequate bladder
drainage with elimination of UTI &stone
formation
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Management ….
Conservative Rx
Catheterization (urethral or suprapubic)
Avoid longe term urethral catheterization to preventurethral injury
Suprapubic catheter can avoid urethral erosion,inflammation & dilation
Prophylactic antibiotic to reduce the incidence ofinfection
Artificial sphincter around the neck of the bladder toprevent urinary incontinence
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Medical management
Aim
↑ing intravesical pressure or ↓ in oulow resistant→↑bladder emptying
Parasympatomimic drugs (bethanechol) stimulate
muscarinic cholinergic ▬↑intravesical pressure Facilitating urine storage by reducing bladder
contraclity or ↑ing oulow resistance
Anticholinergic drugs (propantheline) is effective insuppressing detrusor contractility
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Surgical Mx
For impeding or existing danger to UUT orintractable urinary incontinence (reducedbladder compliance ,a high leak point pressure& detrusor dyssynergia )
Bladder augmentation →ileocystoplastycommonly used , the bladder is bivalved incoronal or sagital plane
Bladder substuon →in pt.with contracted
high pressure bladder
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Surgical Mx…..
Urinary diversion can be either incontinent (urinepass through an open conduit in to external
collecting system) or continent (urine is drained from
bowel reservoir via a catheterizable stoma ) classical
incontinent urinary diversion is the ileal conduit Indian pouch == used cecum ,ascending colon & the
proximal third of transverse colon to construct the
pouch & terminal ileum brought out as a continent
stoma