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UROLOGICAL DISEASES IN MIDDLE AGED MEN AND WOMEN

UROLOGICAL DISEASES IN MIDDLE AGED MEN AND WOMEN. Dr. BIOKU Muftau. OUTLINE. INTRODUCTION CLASSIFICATION OF UROLOGICAL DISEASES COMMON UROLOGICAL DISEASES IN MIDDLE AGED MALES AND FEMALES. INTRODUCTION.

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UROLOGICAL DISEASES IN MIDDLE AGED MEN AND WOMEN

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  1. UROLOGICAL DISEASES IN MIDDLE AGED MEN AND WOMEN Dr. BIOKU Muftau

  2. OUTLINE • INTRODUCTION • CLASSIFICATION OF UROLOGICAL DISEASES • COMMON UROLOGICAL DISEASES IN MIDDLE AGED MALES AND FEMALES

  3. INTRODUCTION • Urological dxs are pathological conditions of male genitourinary tract and female urinary tract. • Account for about 1/3rd of all surgical admissions • Many of the cases are not life threatening • MIDDLE AGE : 45 – 65 YEARS

  4. Male genitalia

  5. CLASSIFICATIONS • URODYNAMIC • ONCOLOGIC • STONES • RECONSTRUCTIVE • ANDROLOGIC

  6. CONT’D URODYNAMIC ONCOLOGIC PROSTATE CANCER BLADDER TUMOUR RENAL TESTICULAR PENILE • BPH • NEUROGENIC DBLADDER • URINARY INCONTINENCE

  7. CONT’D STONE DISEASES ANDROLOGIC ERECTILE DYSFUNCTION MALE INFERTILITY INTERSEX DISORDER • KIDNEYS • RENAL PELVIS • URETER • KIDNEYS • BLADDER • URETHRAL

  8. CONT’D CONGENITAL DXS OTHERS UTI EPIDIDYMO-ORCHITIS URETHRAL STRICTURE PENILE FRACTURE • PUJ OBSTRUCTION • POLYCYSTIC KIDNEY • RENAL AGENESIS

  9. URINARY TRACT INFECTION • Inflammatory response of urothelium to bacterial invasion CLASSIFICATIONS • Urethritis • Prostatitis -Complicated UTI • Cystitis -Uncomplicated UTI • pyelonephritis

  10. Prevalence of UTI

  11. Risk Factors 1. Aging • a. Increased incidence of diabetes mellitus • b. Increased risk of urinary stasis • c. Impaired immune response • Females: short urethra, having sexual intercourse, use of contraceptives that alter normal bacteria flora of vagina and perineal tissues; with age increased incidence of cystocele, rectocele (incomplete emptying) • Males: prostatic hypertrophy, bacterial prostatitis, anal intercourse 4. Urinary tract obstruction: tumor or calculi, strictures

  12. Cystitis - Most common UTI General manifestations of cystitis a. Dysuria b. Frequency and urgency c. Nocturia d. Urine has foul odor, cloudy (pyuria), bloody (hematuria) e. Suprapubic pain and tenderness

  13. Pyelonephritis 1. Inflammation of renal pelvis and parenchyma (functional kidney tissue) Results from an infection that ascends to kidney from lower urinary tract

  14. Manifestations Rapid onset with chills and fever Malaise Vomiting Flank pain Costovertebral tenderness Urinary frequency, dysuria

  15. d. Urine culture and sensitivity e. WBC with differential: leukocytosis and increased number of neutraphils Diagnostic Tests for adults who have recurrent infections or persistent bacteriuria a. Intravenous pyelography (IVP) or excretory urography

  16. b. Voiding cystourethrography c. Cystoscopy d. Manual pelvic or prostate examinations to assess structural changes of genitourinary tract, such as prostatic enlargement, cystocele, rectocele

  17. TREATMENT • Antibiotics used are; Beta lactams Tetracyclines Co- trimoxazole Quinolones Aminoglycosides NitrofurantoinPhenazopyridine • SURGERY :to correct anatomic abnormality

  18. Preventive measures • Good personal hygiene. • Drinking plenty of fluids (water). • Emptying the bladder as soon as urge is felt • Vitamin C makes the urine acidic

  19. BENIGN PROSTATIC HYPERPLASIA

  20. Anatomy PROSTATE

  21. EPIDEMIOLOGY EXCLUSIVELY A MALE PHENOMENON MOST COMMON BENIGN TUMOUR IN MEN MOST COMMON DISEASE OF THE PROSTATE (80%) INCIDENCE IS 1 IN EVERY 10 MEN, AFTER AGE 50 YRS (i.e. AGE-RELATED INCIDENCE) PREVALENCE OF SYMPTOMATIC BPH @ AGE 55YRS = 25% @ AGE 75YRS = 50%

  22. RISK FACTORS Poorly understood; includes : AGING POSITIVE FAMILIAL & GENETIC FACTORS 50% of men < 60yrs undergoing surgery for BPH, have a heritable form of disease Most likely an autosomal dominant trait First-degree relatives of such pxs carry an increased relative risk of ~ 4-fold

  23. AETIOLOGY NOT COMPLETELY UNDERSTOOD APPEARS TO BE MULTIFACTORIAL & ENDOCRINE-CONTROLLED PROSTATE COMPOSED OF BOTH STROMAL & EPITHELIAL ELEMENTS HISTOLOGIC & SYMPTOMATIC BPH CAN ARISE FROM EITHER ELEMENT : Singly, or in Combination

  24. CONTD. • THE DIFFERENTIAL REPRESENTATION OF THE HISTOLOGIC TYPES IN BPH, EXPLAINS IN PART, THE POTENTIAL FOR RESPONSIVENESS TO DIFFERENT MEDICAL THERAPIES • Smooth muscle predominance = α1a – blockers sensitive • Epithelial cell predominance = 5-αreductase inhibitors sensitive • Mixed smooth muscle & epithelial cell predominance = Combination of above two (2) drugs effective • Fibrous tissue/Collagen predominance = No drug effective; an indication for surgery

  25. AETIOLOGICAL CONSIDERATIONS PRESENCE OF FUNCTIONING TESTES Castration results in regression of established BPH & improvement in urinary symptoms Rare occurrence in eunuchs NORMAL ANDROGEN LEVELS INCREASE IN 5-α REDUCTASE ACTIVITY FREE TESTOSTERONE/OESTROGEN IMBALANCE May explain association b/w BPH & aging Suggests that increased oestrogen levels with aging causes induction of androgen receptor Thereby sensitizing prostate to free testosterone No demonstrable elevated oestrogen receptor levels in human BPH

  26. FILLING Frequency & volume Urgency Nocturia Dysuria The Lower Urinary Tract Symptoms (LUTS) VOIDING Hesitancy Weak stream Intermittency Terminal dribbling Feeling of incomplete emptying

  27. BPH and its treatments can provoke sexual dysfunction BPH BPH treatments LUTS Sexual dysfunction

  28. The physical examination 1. Abdominal examination  rule out other possible urinary or rectal conditions 2. Digital Rectal Examination (DRE)  fundamental method for assessing the shape and the volume of the prostate

  29. Standard examination for the detection of: - Haematuria, - Proteinuria, - Pyuria. Urinalysis

  30. The I-PSS is based on the answers to 7 questions concerning urinary symptoms. Each question is assigned points from 0 to 5 indicating increasing severity. The total score can therefore range from 0 to 35 (asymptomatic to very symptomatic). Mild 0-7 Moderate 8-19 Severe 20-35 The I-PSS - symptom assessment

  31. Patient Name: Not at all Less than Less than About More than Almost Your Date: 1 time half the half the half the always score in 5 time time time 1. Incomplete emptying Over the past month, how often have you had a sensation of sensation of not emptying your bladder completely after you finish urinating? 0 1 2 3 4 5 2. Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0 1 2 3 4 5 3. Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated? 0 1 2 3 4 5 The I-PSS Questionnaire Not at all 0 0 0 Less than 1 time in 5 1 1 1 Less than half the time 2 2 2 About half the time More than half the time Almost always Your score 3 4 5 3 4 5 3 4 5

  32. Patient Name: Not at all Less than Less than About More than` Almost Your score Date: 1 time half the half the half the always in 5 time time time 4. Urgency Over the past month, how often have you found it difficult to postpone urination? 0 1 2 3 4 5 5. Weak stream Over the pas month, how often have you had a weak urinary stream? 0 1 2 3 4 5 6. Straining Over the past month, how often have you had to push or strain to begin to urinate? 0 1 2 3 4 5 7. Nocturia Over the past month, how many None 1 time 2 times 3 times 4 times 5 times times did you most typically get or more up to urinate from the time you went to bed until the time you got up in the morning? 0 1 2 3 4 5 TOTAL I-PSS SCORE = The I-PSS Questionnaire (2) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Your score 0 0 0 0 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5

  33. Other recommended tests Objective Test Renal function Creatinine Prostate cancer PSA Flow rate Uroflowmetry PVR Transabdominal ultrasonography Symptoms Voiding diary

  34. TREATMENT OPTIONS MILD SYMPTOMS MODERATE SYMPTOMS MEDICAL THERAPY • WATCHFUL WAITING

  35. SEVERE SYMPTOMS • MINIMAL ACCESS SURGERY • OPEN SURGERY

  36. PROSTATE CANCER

  37. EPIDEMIOLOGY • Most important malignancy in the male genitourinary tract. • 95% of cancers are detected in men 45-89 years old. (median age 72 years.)

  38. EPIDEMIOLOGY. • Eunuchs do not develop Cancer of the prostate gland. • Highest incidence in African-Americans • Most common cancer in men in Nigeria.

  39. EPIDEMIOLOGY. Nigeria – 127/100,000 – 1997. • 5-10% of cancers are inherited in autosomal dominant manner

  40. ETIOLOGY/RISK FACTORS Risk factor Relative risk Obesity 1.25 Dairy products 1.30 Animal fat 1.31 Number of sexual partners 1.21 Vasectomy 1.54 Family history 1.70

  41. PRESENTING SYMPTOMS. • Asymptomatic

  42. IRRITATIVE SYMPTOMS. URGENCY. FREQUENCY. NOCTURIA. OBSTRUCTIVE SYMPTOMS. HESITANCY. POOR URINARY STREAM. URINARY RETENTION. PRESENTING SYMPTOMS.

  43. PRESENTING SYMPTOMS. SYMPTOMS OF METASTASES. • EASY FATIGUABILITY. • PARAPLEGIA. • RESPIRATORY DIFFICULTIES.

  44. D.R.E FINDINGS. • PROSTATE IS ENLARGED. • HARD IN CONSISTENCY. • IRREGULAR. • OBLITERATION OF SULCI.

  45. INVESTIGATIONS. • ULTRASOUND: TRANSRECTAL / TRANSABDOMINAL Heterogenous architecture Hypoechoic areas

  46. INVESTIGATIONS. PROSTATE SPECIFIC ANTIGEN (PSA). HELPFUL IN DIAGNOSIS AND FOLLOW-UP OF CANCER OF PROSTATE. 52% reduction in diagnosis of stage D cases in the USA since use of PSA in diagnosis.

  47. P.S.A • ELEVATED PSA IS HOWEVER NOT CANCER SPECIFIC.

  48. INVESTIGATIONS. • BIOPSY • BONE SCAN • MRI

  49. TREATMENT OPTIONS. • WATCHFUL WAITING.

  50. SURGERY. RADICAL PROSTATECTOMY RADIOTHERAPY. RADICAL: TELETHERAPY BRACHYTHERAPY TREATMENT OPTIONS.

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