Ferji Luts 376j3k

BENIGN PROSTATE HYPERPLASIA (BPH)

Disusun Oleh :  Ferji Rhenald Arditya 1061050010 Pembimbing : dr. Ruyandi Hutasoit, Sp.U KEPANITERAAN KLINIK ILMU BEDAH FAKULTAS KEDOKTERAN UNIVERSITAS KRISTEN INDONESIA Periode 25 Juli – 27 Agustus 2016 JAKARTA

Introduction Lower Urinary Tract consist of vesica urinaria and uretra.

Function of lower urinary tract : storage and voiding urine

Failure function of lower urinary tract can cause lower urinary tract symptoms

These symptoms have widespread human and social implications, causing discomfort, shame and loss of self-confidence

Prevalence LUTS at UK and Sweden are men 72,3% and women 76,3%

Age > 40 years

Urinary Tract anatomy 

Production, storage and avoid the urine



Consist of renal, ureter, vesica urinaria and uretra.



Renal: filtration



Ureter: voiding urine from pielum to vesica urinaria. Ureter wall consist of trantitional cell mocous, circular smooth muscle and longitudinal smooth muscle.

Lower Urinary Tract anatomy 

Vesica urinaria: 3 layers of detrussor muscle; longitudinal muscle, circular muscle, and longitudinal muscle.



Mucosa of vesica : trantitional cell



Uretra: Sphincter uretra interna (smooth muscle)



Woman: uretra 3-5 cm



Man : uretra ....

Micturition MicturitionProcess Process

Lower Urinary Tract Symptoms Consist of: • Storage/iritation symptoms • Voiding/obstruction symptoms • Post-micturition Symptoms

Storage

Urgency Frecuency Nokturia Disuria Slow stream

LUTS

Voiding

Intermittency Hesitancy Straining

Post-micturition

post-micturition dribble a feeling of incomplete emptying bladder

Patofisiology

LUTD

LUTS

Pathofisiology Storage dysfunction

Bladder overactivity (involuntary contraction or decreased compliance) and decreased outlet resistance may cause absolute or relative failure of the bladder to store urine adequately.

Pathofisiology Storage dysfunction

Storage disfunction

Overactivity Bladder Bladder Outlet Underactivity

Bladder Neck Hypermobility Intrinsic Sphincter Deficiency

Pathofisiology Storage dysfunction

1. .

Overactivity Bladder Alterations in nerve and smooth muscle excitability and changes in bladder urothelium composed of neurotransmitters, sensory receptors, and specific ion channels.

. Bladder-related

storage failure may also occur in the absence of overactivity because of increased afferent input from inflammation, irritation, other causes of hypersensitivity, and pain. The causes may be chemical, psychologic, or idiopathic

Pathofisiology Storage dysfunction



2. Bladder Outlet Underactivity urethra ed by the action of the levator ani muscles through their connection to the endopelvic fascia of the anterior vaginal wall.

Damage to the connection between this fascia and this muscle, damage to the nerve supply, or direct muscle damage can therefore influence continence.

Pathofisiology Emptying/Voiding Dysfunction

Absolute or relative failure to empty the bladder results from decreased bladder contractility (a decrease in magnitude or duration), increased outlet resistance, or a combination.

Emptying/Voiding Dysfunction 1.

Detrusor Underactivity

failure of bladder contractility may result from failure or impairment in one of the neuromuscular mechanisms for initiating and maintaining a normal detrusor contraction. Inhibition of the voiding reflex in a neurologically; it may be by a reflex mechanism secondary to increased afferent input, especially from the pelvic and perineal areas, or may be psychogenic

 Non-neurogenic

causes also include impairment of bladder smooth muscle function, which may result from overdistention, various centrally or peripherally acting drugs, severe infection, or fibrosis.

Emptying/Voiding Dysfunction 2. Bladder Outlet Overactivity or Obstruction failure of relaxation or active contraction of the striated or smooth sphincter during bladder contraction. Striated sphincter dyssynergia is other common cause of functional or nonanatomic (as opposed to fixed anatomic) obstruction in patients with neurologic disease or injury. A common cause of outlet obstruction in the female is compression or fibrosis following surgery for sphincteric incontinence

Pathofisiology Post Micturition Symptoms



Postvoid dribbling: involuntary leakage of urine immediately after voiding. Vesicovaginal reflux whereby urine is trapped in the vagina during voiding, and once stands the urine begins to dribble out.



In women, incomplete emptying was more common.

Risk Factor

Age Pregnancy/child birth (especially the first delivery) Overweight

Diagnostic Measure

Anamnesis • information concerning previous pregnancy and delivery, pathological conditions, surgical interventions, radiotherapy to the pelvic region, neurological diseases and previous trauma.

Diagnostic Measure Neurogical exam • anal sphincter tonus • Serious and progresive  Consultation to neurologist

Urine Examination • A simple urinary test should be included in the basic investigation to exclude urinary tract infection and detect haematuria.

Diagnostic Measure Post-voiding residual volume • Post-voiding residual volume is measured either with a catheter post micturition or by a bladder scan. This investigation is important to exclude possible urinary retention.

Diagnostic Measure UrethrocystUrography, computer tomography and/or ultrasoundoscopy • indicated when there is a macroscopic bleeding from the urinary tract, when a tumor is suspected or to check the upper urinary tract in the case of bladder outlet obstruction.

Cystometry • Through fine catheters inserted in the bladder and vagina or rectum the intravesical and intra-abdominal pressures can be measured during filling and micturition.

Management

Behavioural treatment

life-style modification s such as weight loss and smoke cessation

Pelvic Floor Muscle Training (PFMT)

A training programme should always be introduced by a physiotherapist or urotherapist and should include instructions to correctly identify the pelvic floor muscles

Pharmacologica l treatment

Surgical treatment

Estrogen substitution

Correction of urethral hypermobility

Antikolinergik/ antimuscarinic

Duloxetine Desmopressin

strengthening the urethral Strengthening the intrinsic sphincter mechanism

Thank You 