CASE

BPH +
Vesicolithiasis

Patients identity
Name

: Mr Samin
No RM : 131489
Age : 68
Ocuppied :
Address :
Check in : 2 December 2013

ANAMNESIS
Autoanamnesis

Patient complaint cannot voiding spontaneously

since 1 months ago. He said that he always had a
sensation not emptying the bladder completely after
urinating so he had to push or strain to urinate and
had a weak urinary stream everytime he urinating.
He also had frequently to go to the toilet ( 1day
5x) at day and night and also complaint that he
usually stopped and started again several times
when he urinated. He found it difficult to postpone
the urination too.

Treatment

efforts :
He went to doctor with the same
complaint and has been using
catheter since Nov 18th 2013.
IPSS

= 29

Physical Examination
Conciousness:
Vital

CM

Sign
BP : 120/80 mmHg
HR : 84 x/minute
RR : 20 x/minute
Temp: 36,4 OC

Head :
eye : CA -/-, SI -/-, pupils isokor, 3
mm, LP +/+
Neck : lymph nodes doesnt enlarged
Thorax : Cor dan Pulmo within
normal limits
Abdomen : see localized status
Genitalia : catheter foley (+) with
urine 400cc
Extremity : within normal limits

Localized Status a/r Abdomen

Inspection : within normal limits
Auscultation : BS (+) N
Palpation : flat, soepel, pain (+)
,
Percussion : tympani

Investigations
Laboratory

Tests

USG
Thorax

Photo

Laboratory Tests
Eritrosit : 4,91 million/mm3
Leukosit : 12.700 /mm3
Trombosit : 148.000 /mm3
Ht : 44 %
Hb : 14,7 mg/dL
MCV : 30 femtoliter
MCH : 90 picogram
CT : : 4 minutes
BT : 2 minutes
Blood Type : A

SGOT

: 15
SGPT : 12
Ureum : 17,2 mg/dL
Creatinine : 0,7 mg/dL
Glukosa : 86 mg/dL
HbsAg
: negative
Elektrolite :
Kalium : 3,48 mmol/L
Natrium : 153,8 mmol/L
Cl
: 110,2 mmol/L

USG Tests
Vesica urinaria :
The wall wickeness intraluminal, sediment, bladder stones
(+) 7,3 cm.

Prostate
The volume is bigger 51 mL
Parenchym texture echo homogen rough
SOL (-)

Impression :
Severe chronic cystitis

Vesicolithiasis
Prostate Hipertrophy
Right and left renal within normal limits

Thorax Photo
Active

pulmonary TB (-) /
Bronchopneumonia
Cardiomegaly (-)

Working Diagnose
BPH

+ Vesicolithiasis

Follow Up
3

DECEMBER 2013 (HOSPITALIZED DAY 1)

Vital Sign
BP : 130/80 mmHg
Temp : 36,9 C
HR : 80 x/minute, regular
RR : 20 X/minute
Open Prostatectomy catheterized ( catheter no 24 and
catheter cystostomy no 22)
Terapi post op :
Ceftriaxone 2x1 gr
Ketorolac 3x1 amp
Tranexamic acid 3x500 mg
Do a quick spooling droplets, limbs must not be bent

Vesicolithotomy

/ sectio alta

4 DECEMBER 2013 (HOSPITALIZED DAY 2, POST OP DAY

1)

Vital Sign :
BP : 110/70 mmHg
Temp : 36,9 C
HR : 60x/minute, regular,
RR
: 18x/minute
Laboratory Tests:
Eritrosit : 5,03 million/mm3
Leukosit : 17400 /mm3
Trombosit
: 156000 /mm3
Ht
: 45 %
Hb
: 14,9 mg/dL
MCH
: 30 picogram
MCV
: 90 femtoliter
MCHC
: 33 %

 5 DECEMBER 2013 (POST OP DAY 2)

Vital Sign :
BP : 130/70 mmHg
Temp : 37,2C
HR : 96x/minute, regular
RR
: 20/minute
Continue the therapy

 6 DECEMBER 2013 (POST OP DAY 3)

Vital Sign:
BP : 130/90 mmHg
Temp : 38C
HR : 92 x/minute, regular
RR
: 20 x/minute
Do spooling with 40 droplets per minute

DECEMBER 2013 (POST OP DAY4)

Vital Sign :
BP: 140/80 mmHg
Temp : 37,5C
HR : 80 x/minute, regular
RR : 20 x/minute
He complained : nausea(+), vomiting (-), bloating (+)

Urinary Retention
Acute

urinary retention

cannot void with pain, sudden

onset, palpable bladder
Chronic

urinary retention

urine dripping , overflow

incontinence, no pain, palpable
bladder

Cause of urinary
retention
Bladder

outlet obstruction

phimosis, meatal stenosis, stricture

urethra,
traumatic rupture urethra, BPH, Ca
prostate
urethral stone, etc.
Functional

hypoactive bladder

neuropathic bladder, drug, etc.

Pathophysiology
Acute

urinary retention

bladder distension of smooth

muscle, sudden high pressure
in bladder resulting in
suprapubic pain,
no significant effect to upper
urinary tract

Pathophysiology
Chronic

urinary retention

bladder distension of smooth muscle,

slow accumulate high pressure and
residual urine in bladder resulting in
full bladder without pain,
effect to upper urinary tract to cause
bilateral hydronephosis or renal
insufficiency in some cases

Management of urinary
retention
Release

obstruction

urethral catheter
retaining
suprapubic systostomy
Treatment

causes

of the

Bladder Outlet obstruction

Bladder

neck dysfunction
Prostatic enlargement
Urethral stricture
External sphincter dyssynergia
Urethral meatal stenosis
BOO is a condition of progressive
degree

Lower urinary tract symptoms

IPSS & AUA symptom score
Frequency
Urgency
Nocturia
Small

caliber of urine
Dysuria
Intermittency
Residual urine sensation

LUTS and BOO

1/3

of men with LUTS do not have

BOO
5% - 35% of patients with BPH &
LUTS do not improve symptoms
after TURP
LUTS have a poor diagnostic
specificity for BOO
Prostate size and uroflowmetry
have better correlation with
urodynamic study than

Pathogenesis of
Bladder outlet obstruction
Progressive

increased urethral

resistance
High voiding pressure and low flow
Bladder compensation in energy
Increased residual urine volume
Elevated intravesical pressure at endfilling
Bladder stone, diverticulum, UTI
Hydroureter, hydronephrosis, azotemia

Differential diagnosis of
male BOO and LUTS
Benign

prostatic enlargement
Bladder neck dysfunction
Spastic urethral sphincter
Poor relaxation of urethral
sphincter
Urethral stricture
Low detrusor contractility
Pseudodyssynergia due to
neuropathy

Relation of prostate and urethra

Benign prostatic hyperplasia

Prostatic

enlargement benign or
malignant, a sign
Prostatic hyperplasia
histological term
Prostatic obstruction a clinical
diagnosis
Bladder outlet obstruction an
urodynamic term
Lower urinary tract symptoms
symptom

Anatomy of Prostate gland

Anatomy of Prostate gland

Prostatic glandular
anatomy

Cystoscopic Prostatic obstruction

Benign Prostatic
Hyperplasia
BPH

requires testicular androgen

during prostatic development
Basic fibroblast growth factor,
epidermal growth factor,
keratinocyte growth factor,
transforming growth factor-beta
play some part in prostate growth
Decreased endogenous apoptosis
in prostate cause abnormal tissue
growth in prostate

Histology of
Benign prostatic hyperplasia

Causes of symptoms
Hyperplasia

of epithelial and
stromal components of prostate
Progressive obstruction of urinary
outflow
Increased activity of detrusor
muscle
Causes
Frequency, nocturia
Poor flow , intermittent stream
Hesitation, terminal dribbling

Prevalence
Men

> 50 = 41% have

symptoms of LUTS
Only 18% have a
diagnosis
Only 10% aware of drugs
or surgery that will help it

Clinical BPH
LUTS

( storage or empty
symptoms) due to histological
benign prostatic hyperplasia and
urodynamical bladder outlet
obstruction which has been
proven by urodynamic pressure
flow study as prostatic
obstruction
Treatment for LUTS and
restoration of normal storage and
empty function by reducing
prostatic enlargement either

Pathophysiology of
BPH and LUTS
Nodular

proliferation of prostate

gland
Increased stroma to epithelial
ratio to 2:1 to 5:1 in benign
prosatic hyperplasia
Increased smooth muscle
component
Detrusor compensatory change
and bladder dysfunction, detrusor
overactivity

Examination
Palpation

of abdomen for

enlarged bladder
enlarged kidneys
constipation
Rectal

examination for

Size and consistency of prostate

gland

Investigations

Blood tests
Fbc esr
U&es
Fasting blood sugar
? PSA level rises with increasing
volume of prostate gland

Urinalysis
Infection
haematuria

Investigations
Additional

tests as
appropriate by GP
Ultrasound for residual urine
volume
Urinary diaries

Specialist investigations
Reasons

for doing them

Patient reassurance
Patient explanation
Objective assessment of symptoms
Diagnostic precision
Ranking of treatment options
Prediction of treatment outcome

Specialist investigations
Uroflowmetry

max flow rate and volume of residual urine

after voiding low flow rate indicates need
for TURP
Bladder

pressure studies

pressure measurement during filling and

emptying (cystometry) gives information
on over/under activity of detrusor muscle
and obstruction of bladder outlet. Predicts
response to treatment. Use antimuscarinics
for over activity and turp for bladder outlet
obstruction

Specialist investigations
Urinary

tract imaging

Ultrasound to estimate residual urine

Urethroscopy

Visual inspection of bladder and

uerethra is used in dysuria or
haematuria

Assesment

A validated questionnaire using

international prostate symptom
scale.
Completion gives total score of 35
1 7 mild
8 19 moderate
20 35 severe

Response to the quality of life

questionnaire strong predictor or
whether intervention is necessary

Scoring System (IPSS)

Ask 7 questions. Answers on scale 0
5 depending on severity of symptoms
For first 6 questions scores are

Not at all = 0
< 1 in 5 = 1
< half the time = 2
About half the time = 3
> half the time = 4
Almost always = 5

Q7
Never = 0, once = 1, 2x = 2, 3x = 3, 4x =
4, 5x = 5

Therapeutic modalities for LUTS

ascribed to the prostate
Watchful

waiting and fluid

restriction, natural history of BPO
may wax and wan
Medical treatment to reduce
prostate size or decrease
intraprostatic resistance
Surgical treatment to remove
prostatic obstruction or reduce
urethral resistance
Minimally invasive therapies

Surgical Treatment for

BPH
Suprapubic

& retropubic
prostatectomy
Transurethral prostatectomy
(TUR-Prostate)
Laser interstitial prostatectomy
Transurethral incision of prostate
Intraprostatic stent
Balloon dilatation of prostatic
urethra
Prostatic hyperthermia

Prostate Resectoscope and TURP

Indication for Surgery

There are complications, including:
(1) retention of urine due to BPO,
(2) infection recurrent urinary tract due
to BPO (benign prostatic obstruction),
(3) macroscopic hematuria due to BPE
(benign prostatic enlargement),
(4) vesicolithiasis due to BPO,
(5) renal failure caused by the ODS, and
(6) bladder diverticulum-pot large
enough for BPO

Indications for Open

Prostatectomy
Acute

urinary retention
Persistent or recurrent urinary tract infections
Significant hemorrhage or recurrent
hematuria
Bladder calculi secondary to bladder outlet
obstruction
Significant symptoms from bladder outlet
obstruction that are not responsive to
medical or minimally invasive therapy
Renal insufficiency secondary to chronic
bladder outlet obstruction

Complications of TURProstate
Peri-operative

bleeding
Urinary tract infection and urosepsis
Electrolyte imbalance, hemolysis,
acute tubular necrosis
Acute pulmonary edema
Bladder neck or urethral contracture
Retrograde ejaculation and erectile
dysfunction
Urge or stress urinary incontinence

Minimally invasive
procedure
Transurethral

vaporization- resection of
prostate (TUVRP)
Ho-YAG laser coagulation of prostate
Visual laser ablation of prostate (VLAP)
Transurethral needle ablation (TUNA)
High intensity focused ultrasound (HIFU)
Microwave hyperthermia
Minimally invasive = minimally
effective?
A higher re-treatment rate than TURP
although less complication occurs

Intra-Prostatic Stent

Interstitial Laser
Coagulation

Hyperthermia of BPH

Transurethral Dilatation of
Prostate

Medical Therapy for BPH

Prostatic

smooth muscle tension

was mediated by alpha 1adrenoreceptors
Smooth muscle contractions
contribute 40% of outflow
obstruction
Alpha 1- blockers can rapidly
improve Qmax and relieve LUTS
Phenoxybenzamine, terazosin,
doxazosin have side effect of

Prostatic specific
alpha- adrenoreceptor
Alpha

1A- AR subtype comprises

70% of all alpha-1 receptors
Alpha 1A-AR agonist tamslosin
has 13 x more affinity to prostatic
smooth muscle than urethral
muscle , 10 x than vascular
smooth muscle
Side effects are still reported
Long-acting (once daily) dose

Hormone based medical

therapy
5-alpha-reductase

catalyzes
conversion of testosterone to
dihydrotestosterone
Inhibition of 5-alpha-reductase
can arrest prostatic growth and
relieve obstruction
Finasteride can improve
symptom score,Qmax, QOL score
Effective especially in prostatic
weight of >40 gm and effective

Combination therapy with alphablocker and finasteride

Terazosin

is effective therapy,
finasteride was not, combination
was no more effective than
terazosin alone
Combined dibenyline and
finasteride has an additive effect
than dibenyline or finasteride
alone in improvement of Qmax
and prostatic size

Vesicolithiasis / bladder
stone
Bladder

(vesical) calculi are

stones or calcified materials that
are present in the bladder (or in a
bladder substitute that functions
as a urinary reservoir). They are
usually associated with urinary
stasis but can form in healthy
individuals without evidence of
anatomic defects, strictures,
infections, or foreign bodies.

Etiology
Prostatic

enlargement

Epidemiology
Since

the 19th century, the incidence of

primary bladder calculi in the United States
and Western Europe has been steadily and
significantly declining as a consequence of
improved diet, nutrition, and infection control.
In these countries, vesical calculi affect adults,
with a steadily declining frequency in children.
In the Western hemisphere, vesical calculi
primarily affect men who are usually older
than 50 years and have associated bladder
outlet obstruction.

Stone composition
Calcium

stones
Calcium oxalate
Pure calcium phosphate
Magnesium ammonium
phosphate
Uric acid
Cystine

Pathophysiology
Most

vesical calculi are formed

de novo within the bladder, but
some initially may have formed
within the kidneys as a
dissociated Randall plaque or on
a sloughed papilla and
subsequently may have passed
into the bladder, where additional
deposition of crystals cause the
stone to grow.

Clinical Presentation
Suprapubic

pain

Dysuria
Intermittency
Frequency
Hesitancy
Nocturia
Urinary

retention
Gross hematuria

Examination
BNO-

ivp

USG
Cystoscopy
CT-

scan

Complication
Infection
Retensio

urine