Problèmes mictionnels:

Présentation au sujet: "Problèmes mictionnels:"— Transcription de la présentation:

1 Problèmes mictionnels:
Que faire en cabinet? Alain BITTON, Urologue FMH Alain BITTON, Urologue FMH Centre médical des Eaux-Vives Sous l’égide de This slide can be easily personalised by just clicking on “Speaker’s name”, “Venue” and “Date”, and entering the alternative text.

2 Embryologie D’où vient la prostate ?
La prostate entoure la partie initiale de l’urètre, envahissant le mésenchyme environnant This is a view of the lower urogenital tract of the embryo of 44 days of development. (note that the photograph shown in the background is that of a fetus, but is used to enhance understanding (see credits)) The cloaca has already been separated by the urorectal septum at about 28 days of gestation [1] and thereafter the rectum and the primitive urogenital sinus are evident. The primitive urogenital sinus proximal to the mesonephric duct becomes the vesicourethral canal, whereas the region distal to the mesonephric duct develops into the definitive urogenital sinus. The urogenital sinus adjacent to the bladder (the pelvic urethra) is narrow and develops into the liower portion of the prostatic and membranous urethra. [2] At about the tenth week of gestation, the ductal network within the prostate originates from solid epithelial outgrowths, or prostatic buds. These prostatic buds emerge from the endodermal urogenital sinus immediately below the bladder and penetrate into the müllerian mesoderm which develops into the utricle and the mesonephric mesoderm which develops into ejaculatory ducts. [3, 4]. References: Stephens F D. Congenital malformations of the urinary tract. New York: Praeger, 1993 Hamilton WJ, Mossman HW. The urogenital system. In: Human embryology: prenatal development of form and function, 4th ed. New York: Macmillan, 1976: 201. Johnson FP. The later development of the uretrha in the male. J Urol 1920; 4:447 Lowsley OS. The development of the human prostate gland with reference to the development of other structures at the neck of the urinary bladder. Am J Anat 1912; 13:

3 La prostate enveloppe totalement l’urètre et est située sous la vessie
Embryologie So, as always, embryology teaches us two important lessons: The first one is that the prostate surrounds the urethra completely, is located under the bladder, and contains the prostatic urethra.

4 épithéliale (glandulaire)
Le tissu prostatique est formé de deux composantes stromale - le mésenchyme, un muscle lisse The second lesson is that the prostate gland is composed of two histologicaly distinct tissue compartments – a branching acinar- ductal epithelium and a fibromuscular stroma. Morphometric analyses have demonstrated that each compartment (When luminal spaces are considered part of the epithelial compartment) make up about one- half of the glandular volume of the human prostate [1]. Each of these tissue elements is further composed of a variety of cell types, including secretory and basal epithelial cells, smooth muscle cells, undifferentiated fibroblasts, nerve bundles and inflammatory cell infiltrates. The prostatic stroma provides a supporting matrix for the ductal epithelial cells, shich synthesize,concentrate and secrete the components of the prostatic fluid into the ductal lumina, including the prostatic specific antigen. In addition, the connective smooth muscle compartment mediates contractions required to expel the prostatic secretions from the gland. There is strong evidence from experimental models that the stromal and epithelial compartments communicate with each other, and that prostatic growth and functional diffrerentiation, both during development and in the adult, are dependent on regulatory signalling between them. References: 1. Deering RE, Bigler SA, King J et al. Morphometric quantitation of stroma in human benign prostatic hyperplasia. Urology 1994; 44:64–70. épithéliale (glandulaire)

5 L’homme et sa prostate…
We will start with an overview of the anatomy and function of the genitourinary tract, and we will later focus on the prostate.

6 Les voies génito-urinaires ont deux fonctions élémentaires :
Les voies urinaires Les voies génito-urinaires ont deux fonctions élémentaires : 1. La miction 2. L’éjaculation There are two basic functions of the genitourinary tract: Urination - The production of urine by the kidneys, storage in the bladder and micturition through the uretrha. Ejaculation – The production of sperm in the testis, and seminal fluid in the prostate and seminal vesicles and it’s ejaculation through the vas deferens, ejaculatory ducts and urethra. The urinary system and the genital system join at the prostate, and share the urethra.

7 Les voies urinaires 2. L’éjaculation
This is a closer look at the path that sperm follows from the testicle towards the outside world.

8 Imagerie par résonance magnétique (IRM)
uretère vésicules séminales vessie prostate This is a Magnetic resonance reconstruction of the bladder and prostate, where their close relationships can be observed. (see credits) bourgeons neurovasculaires plexus veineux urètre

9 Anatomie : urètre et sphincters
We will use a three dimensional model of the prostate to understand the zonal anatomy of the prostate. The “skeleton” of this model is the prostatic uretrha. The prostatic uretrha is the widest and most dilatable part of the entire male urethra. It is about 3 cm long and extends through the prostate from base to apex. It is divided into proximal and distal segments of approximately equal length by an abrupt anterior angulation of its posterior wall at the midpoint between the prostate apex and bladder neck. The angle of deviation is approximately 35 º, but can be quite variable and tends to be greater in men with nodular hyperplasia. The colliculus seminalis or veru montanum forms an elevation on which the ejaculatory ducts drain. It also contains the prostatic utricle (not showed). There are two urinary sphincters, the distal, external or volunctary sphincter (depicted in red, narrow), and the proximal, internal, preprostatic or involunctary sphincter (depicted also in red, wide). Deux sphincters prostatiques : Externe – volontaire – sa contraction interrompt le débit urinaire Interne – involontaire – sa contraction empêche l’éjaculation rétrograde

10 Anatomie : éjaculation normale
Les stimuli sympathiques déclenchent : 1. La contraction du sphincter interne qui permet d’empêcher le reflux du sperme dans la vessie 2. Les contractions de la vésicule séminale et des canaux déférents Ejaculation is antegrade in the presence of a competent preprostatic sphincter. There is a tightening of the sphincter on erection, which becomes more marked in the period leading up to ejaculation. A sympathetic stimuli provokes the contraction of the vas deferens and seminal vesicles. This video shows a fictious simultaneous contraction of the sphincter and involunctary sphincter, that will allow to understand the mechanism by which damage of the internal sphincter by surgery or other means can lead to retrograde ejaculation. L’éjaculation

11 Anatomie : stroma fibromusculaire antérieur
Contient une faible quantité de glandes Généralement constitué de fibres musculaires lisses The largest part of the prostate is the anterior or ventral fibromuscular stroma, which forms the ventral surface of the gland and which constitutes about one-third of the entire prostate.

12 Anatomie : zone centrale
25% du volume glandulaire Fréquence de cancer moyenne : 20 % The central zone comprises about 25 % of the glandular prostate. This zone is wedge shaped and surrounds the ejaculatory ducts with its apex ate the veru montanum and its base against the bladder neck. Thus, the central zone is, at least in its distal part, surrounded by the peripheral zone and its ducts open into the prostatic urethra, in close proximity to the ejaculatory ducts. The central zone, like the peripheral zone, has a funnel shape to accommodate the proximal segment of the urethra. Both funnels are held together by the anterior fibromuscular stroma.

13 Anatomie : zone périphérique
70% du volume glandulaire chez les jeunes adultes Lieu d’origine du cancer de la prostate (70% des cas) Plus facilement palpable au toucher rectal The peripheral zone represents about 70 % of the glandular part of the prostate. This zone forms the lateral and posterior or dorsal part of the organ. It may be regarded as a funnel that distally constitutes the apex of the prostate and crenially opens to receive the distal part of the wedge-shaped central zone. Most prostate cancers arise here, and it’s close proximity with the rectum explains why this zone is easily assessed by a digital rectal examination.

14 Anatomie : zone de transition
5% du volume glandulaire chez les jeunes adultes Lieu d ’origine de l’HBP Faible incidence de cancer (25 %) The transitional zone is the smallest glandular part of the prostate and comprises only about 2 – 5% of the prostate. It consists of two independent small lobes whose ducts leave the posterolateral recesses of the urethral wall at a single point, just proximal to the point of urethral angulation and at the lower border of the preprostatic sphincter. BPH is not a diffuse and generalised disease of the prostate but is a highly localised disease of the smallest area of the prostate (the transition zone and the periuretrhal gland area).

15 La prostate et ses maladies:
1. Cancer nouveaux cas en Europe décès 2. Inflammation 3. Hyperplasie prostatique 30% de la population masculine recherchent un traitement La prostate et ses maladies:

16 présidence de la République «
« Il y a deux organes inutiles: la prostate et la présidence de la République «  Georges CLEMENCEAU

17 Prévalence d’une HBP clinique
30 ans : aucun symptôme 50 ans: 2 sur 10 70 ans: 4 sur 10 The prevalence of BPH increases from about 8 % in the fourth decade of life to 90 % in the ninth [1,2]. One half of the men with microscopic evidence of BPH will have macroscopic enlargement of the gland, and approximately one half of those men will develop clinical symptoms. References: Berry SJ, et al. The development of human prostatic hyperplasia with age J. Urol, 1984; 132:474 – 479 Boyle P. Et al. Epidemiology and natural history of BPH. In Cockett ATK, Khoury S. Et al. Proceedings of the second international consultation on Benign Prostatic Hyperplasia. Paris, June 27-30, 1993: 19 – 28. 80 ans: 6 sur 10

18 Espérance de vie chez les hommes en Suisse
2000: 79,6 ans 2025: 82,3 ans Life expectancy continues to increase in Switzerland. (Data from the US Bureau of the Census).

19 HBP: étiologie Deux éléments sont nécessaires au processus :
La fonction testiculaire L’âge Plusieurs théories impliquent : La dihydrotestostérone L’enzyme 5 alpha- réductase Les interactions stromales-épithéliales Une réduction de l’apoptose Les cellules souches The only proven risk factors for developing BPH are ageing and the presence of functioning testes [1], assuming that the prostate was normal to start of with – in other words, if 5 – alpha reductase was present to convert testosterone to dihydrotestosterone and there were functioning androgen receptors for the dihydrotestosterone to bind to. There are several theories that explain the pathogenesis of the disease. It is quite clear that BPH is not a diffuse generalised disease of glandular epithelium due to an altered androgen:oestrogen ratio. It is a focal, stromal-induced disease affecting the transition and periurethral zones, producing micronodule formation by a stromal – epithelian interaction that appears to be mediated by growth factors. Androgen appears to act through transforming growth factor alpha expression to regulate the expression of other growth factors. References: 1. Mc Neal JE. The pathobiology of nodular hyperplasia. In: Bostwick DG (ed) Pathology of the prostate. New York: Churchill Livingstone, 1990: 31 – 6.

20 HBP: Physiopathologie
Let’s focus on the physiopathology, this is, how BPH originates symptoms and signs.

21 Qu’est-ce que l’HBP ? Aucune définition n’existe vraiment, mais les urologues la décrivent généralement comme : une hyperplasie histologique (biopsies, chirurgie) ou clinique (hypertrophie de la prostate détectée au toucher rectal ou par échographie) des symptômes ou “prostatisme” une obstruction au débit urinaire (pressure flow studies) Hyperplasie Symptômes Obstruction There is still no definition of BPH. The clinical picture of BPH is determined by three independent variables: symptoms, benign prostatic hyperplasia and bladder outflow obstruction.

22 Origine des symptômes et complications ?
1. Obstruction: Composante statique Composante dynamique 2. Réponse de la vessie > Contractilité < Contractilité It is important to understand that the cause of bladder obstruction has two underlying components: a static component related to the increase in size of the prostate which can result in mechanical compression of the urethra, and a dynamic component related to smooth muscle tone of the prostatic musculature.

23 Obstruction: Composante statique
1. volume prostatique = résistance augmentée This image shows the static component of obstruction. It is important to note that PROSTATE SIZE ALONE DOES NOT CORRELATE WITH SYMPTOM SEVERITY. In BPH, there is a significant increase in the amount of fibromuscular tissue and a relative decrease in the glandular area compared to the normal prostate, although the balance of tissues affected varies from man to man. This may explain why prostate size is not related to severity of symptoms or obstruction. In the normal prostate, the ratio of fibromuscular to glandular tissue is 2/1. In BPH this ratio is 5/1.

24 Obstruction: Composante dynamique
Le muscle lisse de la prostate est très fortement innervé Vessie : parasympathique This slide shows the innervation of the bladder, prostate and external, volunctary sphincter. Sympathetic stimulation results in an increased stimulation of alpha 1 adrenoceptors in the bladder neck and prostate. The dynamic component of prostatic obstruction relates to the contractile properties of the smooth muscel in the bladder neck, urethra and prostate. The prostatic stroma, composed of smooth muscle and collagen, is rich in adrenergic nerve supply. The level in autonomic stimulation thus sets a tone to the prostatic urethra. Use of alpha blocker therapy decreases this tone, resulting in a decrease in outlet resistance. Prostate et col vésical : sympathiques Sphincter externe : volontaire

25 Réponse de la vessie à l’obstruction
As the development of BPH is insidious, changes within the lower unirary tract occur gradually, often making them difficult for the patient, his partner or relatives to perceive. As in other smooth muscle systems, the response of the detrusor to obstruction is a combination of smooth muscle cell hypertrophy and connective tissue infiltration [1]. In addition, the density of parasympathetic nerves is significantly reduced. This leads to a relative denervation of the smooth muscle, which responds by secondary detrusor instability [2]. Detrusor instability is in most instances secondary to obstruction (70 % improve after TURP, suggesting that this allows the bladder to improve, and the pathophysiological changes to reverse), although it can also be an age-related abnormality of bladder contractility that occurs in both sexes that coincidentally develops as the same time as BPH in some men. Impaired detrusor contractility is also common in the elderly of both sexes. It rarely, if ever, improves after TURP. This fact and the fact that experimental models of obstruction cause a thick walled, trabeculated, high pressure, unstable bladder and not chronic retention [3] support the view that impaired detrusor contractility is an age-related condition rather than secondary to obstruction, as it has always been assumed. The view that impaired contractility – causing residual urine initially, progressing eventually to chronic retention with overflow incontinence – arises as a result of decompensation of the detrusor in the face of continuing obstruction after an initial phase of compensation seems flawed. It is probably more correct that if obstruction is superimposed on impaired detrusor contractility, the consequences are correspondingly more severe, and probably these patients are prone to high pressure retention and renal impairment as a result. References 1. Gilpin SA, Gosling JA, Barnard RJ. Morphological and morphometric studies of the human obstructed, trabeculated urinary bladder. Br J Urol 1985; 57:525-9 2. Speakman MJ, Brading AF, Glipin CJ, et al. Bladder outflow obstruction: cause of denervation supersensitivity. J. Urol 1987; 138:1461-7 3. Dixon J, Gilpin C, Gilpin S, et al. Sequential morphologic changes in the pig detrusor in response to chronic partial urethral obstruction. Br. J. Urol 1989; 64:385-90 Contractilité du détrusor altéré Diminution de la pression et du débit urinaire Contractilité excessive du détrusor Instabilité vésicale ou contractions involontaires du détrusor

26 Symptômes irritatifs (lors du remplissage)
Nycturie Polakiurie Miction impérieuse Besoin impérieux Altération des fonctions vésicales The symptoms of BPH fall into two main categories, namely irritative (or filling) and obstructive (or voiding) with the former usually being the most bothersome [1] Where irritative symptoms occur in the complete absence of concurrent obstructive symptoms, the suspicion of bladder cancer or other bladder pathology should be considered. References Abrams P. Managing lower urinary tract symptoms in older men. Br Med J, 1995;310:

27 Symptômes obstructifs (lors de la vidange)
Difficultés à la miction Retard à la miction Faiblesse du jet urinaire Miction prolongée Résidu post-mictionnel Sensation de vidange incomplète Miction par regorgement The slide lists the obstructive or emptying phase symptoms suggestive of BPH.

28 Infections urinaires récurrentes Formation de calculs
Ces symptômes peuvent entraîner de sérieuses complications : Infections urinaires récurrentes Formation de calculs Trabéculation vésicale et diverticules Hydronéphrose Hémorragie Rétention urinaire aigüe Rétention urinaire chronique Insuffisance rénale It can also be a source of serious complications.

29 Hydrouretère Hydronéphrose Insuffisance rénale
Some examples of complications of BPH. High pressure chronic retention leads to hydroureter, hydronephrosis and eventually renal impairment.

30 Some examples of complications of BPH
Some examples of complications of BPH. Postvoid residual urine favours urinary infection and lithogenesis.

31 Formation de calculs Some examples of complications of BPH. Postvoid residual urine favours urinary infection and lithogenesis.

32 Diverticule Some examples of complications of BPH. Diverticula formation. A complication of obstructed bladders, where bladder trabeculation and the herniation of the mucosa through muscle fibers leads to this complication that complicates the clinical picture of BPH. Large diverticula can cause double voiding, UTIs and stones.

33

34 Bilan urologique Anamnèse et score IPSS Examen général & TR
Sédiment urinaire Débitmétrie Mesure du résidu postmictionnel US abdominal: Reins, vessie, prostate Urée, créatinine Optionnel: cystoscopie, bilan urodynamique

35 Diagnostic: US allows to measure the post-void residual urine volume. Increased PVR may result from obstruction or reduced detrusor contractility, but PVR varies considerably daty to day and from void to void, and so treatment decisions cannot be made on the basis of this test alone. PVR values greater than ml suggest an increased risk of urinary retention and may indicate the need of surgery. Uroflowmetry is a means of assessing the likelihood of outflow obstruction being present.

36 Evaluation de l’HBP ultrason transrectal

37 Bilan urologique PSA total et PSA libre PSA complexé ? CAVETE:
Pas de massage prostatique, US ou cystoscopie avant mesure Peuvent augmenter le PSA: Prostatite aiguë ou chronique Ejaculation Compression chronique du périnée: Vélo...

38 Ne pas oublier que l’HBP est très souvent associée
à une prostatite Ne pas traiter l’une sans l’autre !

39 Diagnostic : The clinical laboratory assessment is quite simple.
Measurements of serum levels of PSA helps estimating the risk of cancer. It is important to counsel patients as tihis test may lead to uncertainty and create the necessity for further invasive tests. This optional test is not recommended routinely beyond the age of 70 years.

40 Le PSA: marqueur idéal ? Pas de cancer ng/mL 0.0 4.0 100
100% sensibilité 100% spécificité

41 Mesure du PSA: la réalité…
Pas de tumeur Cancer de la prostate ng/mL

42 Problème supplémentaire: HBP
ng/mL

43 Formes circulantes du PSA
Après sécrétion depuis la prostate dans la circulation, la majorité du PSA est liée irréversiblement à l’alpha-1-antichymiotrypsine et à l’alpha-2- macroglobuline

44 PSA sérique ACT PSA complexé 60 - 95% ACT PSA PSA ß-2-M PSA
PSA libre %

45 Prostate Sérum SERUM PSA libre (inactif) Tumeur Aktives PSA
(wird PSA-ACT) SERUM HBP Prostate ? Plus de PSA inactif (PSA libre) Sérum Plus de PSA actif (complexe PSA-ACT)

46 ACT ACT ACT % PSA libre 30 10 Cancer HBP HBP Cancer PSA PSA PSA ACT
Glande normale Cancer Cancer HBP HBP % PSA libre 30 10 Taux PSA-ACT faible Taux PSA-ACT élevé Taux PSA-ACT élevé Taux PSA-ACT élevé ACT ACT ACT ACT PSA PSA PSA PSA

47 TRAITEMENT (S): QUOI ET POUR QUI ?

48 Architecte, 57 ans, très pressé
PSA 5.6 ng/ml lors d’un check-up de routine TR: petite prostate avec nodule ferme à D Bilan sanguin et sédiment urinaire sp Veut une « opération de la prostate au laser… »

49 "But, Doctor, I read it on the Internet !"

50 Objectif du traitement: amélioration des symptômes
sans risque pour le patient

51 Slide is self-explanatory.

52 Médicaments Phythothérapie: patient peu gêné ou jeune; IPSS < 7
Alpha-bloquants: si lobe médian ou symptômes modérés; 7 < IPSS < 15 Finastéride si saignements ou prostate > 40 cc

53 Toujours aborder le problème en pensant à la qualité de vie du
patient !                                                                          

54 Phytothérapie: méthode douce…

55 Les produits… Saw palmetto: petit palmier qui pousse spontanément en Floride et au Texas Pygeum africanum: Variété de prunier qui pousse dans les montagnes d’Afrique centrale Graines de courge: actifs grâce aux phytostérols que contient le pépin de courge Zinc en association: Protection de la prostate contre le vieillissement Sélénium ? Vitamine E ?

56 Mécanismes d’action Anti-inflammatoire: inhibition de la production de
5 lipoxygénase et de l’acide arachidonique Anti-oedémateux Anti-androgène: diminution de la concentration plasmatique de la dihydrotestostérone Réduction de la prolifération des cellules prostatiques Augmentation de l’élasticité de la vessie

57 Indications Patients jeunes 35 – 55 ans, peu gênés En association avec quinolones pour prostatite à tout âge

58 Les alpha-bloquants ou
comment remonter la pente…

59 L’HBP occasionne une obstruction par 2 mécanismes:
Logique de l’utilisation des alpha-bloquants L’HBP occasionne une obstruction par 2 mécanismes: Compression mécanique: adénome Obstruction dynamique: musculature lisse prostatique

60 Terminaison nerveuse sympathique
La stimulation autonome du récepteur alpha adrénergique augmente le tonus de l’urètre prostatique Physiopathologie Terminaison nerveuse sympathique Membrane Espace synaptique Muscles lisses prostatiques TN Alpha - 1 Adrénergique This is the mechanism by which the simpathetic nerve endings release noradrenaline, that through the stimulation of the alpha adrenergic receptor results in the induction of smooth muscle contraction, and sets a high tone in the prostatic urethra. This slide gives a chance to remind the audience that the alpha receptors are further subdivided as alpha-1 and alpha-2 subtypes. Alpha-2 are presynaptic in location and serve to regulate the amount of neurotransmitter transmission across the synapse. Norepinephrine is the primary neurotransmitter and stimulation of the alpha-2 receptors results in feedback inhibition of norepinephrine release. Becuse of their wide distribution, blockade of alpha-2 receptors results in significant systemic and cardiac effects. There are three subtypes of alpha 1 receptors, alpha 1a, 1b, and 1d. Récepteur Induction de la contraction du muscle lisse

61 Les récepteurs alpha et la vessie
La prostate exprime principalement a-1a (70 %) Le muscle de la vessie exprime a-1d > a-1a It is important to understand that

62 Terminaison nerveuse sympathique
Alphabloquants : Mode d’action. Terminaison nerveuse sympathique Espace synaptique Membrane Muscles lisses de la prostate Alpha Adrénergique TN Récepteur Mode of action of alpha blockers. Relâchement du muscle lisse

63 50 % de la pression urétrale est due
à un tonus musculaire a-1 adrénergique Les alpha-bloquants diminuent ce tonus, entraînant ainsi une moindre résistance au flux urinaire Alpha adrenergic receptor blockers, as Xatral uno, act relaxing the tone of the smooth muscle in the prostate, decreasing bladder outlet resistance, although, as we will see later, there are other mechanisms that justify their clinical effectiveness.

64 Efficacité des alpha-bloquants: Alfuzosine 10 mg
Améliore de façon rapide et durable les troubles de la miction Diminue le risque de complications aigües et d’hospitalisation Ne gêne pas la sexualité A prendre seulement une fois par jour Efficacité maintenue pendant 24 h Slide is self-explanatory.

65 Effets secondaires des alpha-bloquants
Vertiges Céphalées Hypotension orthostatique / hypotension Syncope Malaise

66 La transformation… … est-elle possible ?

67 Finastéride Propécia… pour les cheveux Proscar… pour la prostate

68 Traitement hormonal: Finastéride
Inhibiteur de la 5 alpha réductase : inhibition compétitive de la 5 alpha réductase, (bloque la transformation de la testostérone en dihidrotestostérone) Réduit la taille de la prostate de 30 % augmente le débit urinaire et atténue les symptômes mais nécessite 6 à 12 mois pour agir de façon optimale diminue le PSA (env. de 50 %) affecte les fonctions sexuelles : réduit la libido, réduit le volume de l’éjaculat, impuissance réversible chez 3 à 5% des patients. Semble être plus efficace avec les prostates > 40 cm3 Réduit le nombre d’interventions chirurgicales de 50% en cas de RUA et d’HBP s’il est pris régulièrement pendant plus de deux ans. Slide is self-explanatory.

69 Le traitement et la prise en charge
de l’HBP est aussi un problème de couple: répercussions sur la sexualité, problèmes d’éjaculation, libido…

70 Chirurgie D’emblée si obstruction ou rétention
Moyen ou long terme si inefficacité des autres traitements TURP ou alternatives moins invasives à discuter avec le patient Toujours penser « qualité de vie » Répercussions fonctionnelles: Ejaculation ? Incontinence ?

71 Diagnostic ? Radiographie sans contraste
Some examples of complications of BPH.

72 Dilatation vésicale chronique
Radiographie sans contraste Dilatation vésicale chronique > 3 litres Some examples of complications of BPH.

73 Some examples of complications of BPH. Acute urinary retention
Some examples of complications of BPH. Acute urinary retention. AUR is a common complication of BPH and can occur at any stage of obstruction. The pathophysiology is multifactorial: a direct relationship with lower urinary tract symptoms, depressed peak flow rate, enlarged prostate, old age and post-void residual volume (PVR) [1]. The presence of PVR is associated with a decreased functional bladder capacity and has been identified as a predictive factor of AUR. In an analysis of PVR measured by transabdominal ultrasonography in 2115 patients it was shown that a high PVR at baseline confers a 3-fold risk of developing AUR [2]. References: 1. Jacobsen SJ, et al. A population based study of health care seeking behavior for treatment of urinary symptoms – The Olmsted county study of urinary symptoms and health status among men. Arch Fam Med 1993; 2: 2. Kolman C et al. Post-void residual urine volume in randomly selected community men in Olmsted County, Minnesota. J. Urol, 1998;159:139

74 Hey ! com’on… it’s not brain surgery

75 Incision transuréthrale de la prostate: résection du col vésical
Slide is self-explanatory. Plus simple à effectuer que la résection complète Tout aussi efficace sur des prostates de petite taille

76 Résection transuréthrale
Gold standard Plus agressive Slide is self-explanatory.

77 Chirurgie ouverte ?

78 Prostatectomie rétropubienne ou transvésicale: Millin ou Freyer
Ablation du tissu hyperplasique. La capsule reste en place Seulement pour les très grandes prostates > 60 – 100 g Opération très efficace Slide is self-explanatory.

79 Nouvelles technologies: Stent

80 Nouvelles technologies
Holmium Laser

81 Nouvelles technologies: Holmium Laser
Idéal pour les petites prostates < 35 g Peu ou pas de saignement Sondage 24 h / chirurgie de jour Patients anticoagulés ou sous aspirine

82 Nouvelles technologies: thermothérapie
Idéal pour les grosses prostates > 60 g Patients inopérables ou sous anticoagulants Sédo-analgésie Pas de chirurgie Effet à long terme: nécrose de coagulation Efficacité comparable à la TURP

83 Mais… laissez aussi le patient poser ses questions et suscitez la discussion !

84 There is reluctance by patients to discuss their symptoms suggestive of BPH with the doctor. The use of 3 simple questions can help GPs to identify patients who deserve further evaluation.

85 « Ok Doc, I’ll give up my PC ! »