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Uh good afternoon to your um you know, urology is a secondary subject in undergraduate training. But I would think there are three important topics which you need to know. Uh I'm talking from UK point of view, but it holds crew for every uh university in the world. One is prostate. The prosthetic disease are very important. And the second one is hematuria, blood in the urine. And the third one is urinary tract infections and septicemia. So today, we will just concentrate on prostate because it is such a volume anus subject. I have divided it into two parts and I will only pick up very important topics so that you don't have to uh you know, scratch your head and think about the topics. Obviously, you need to know a little bit about physiological anatomy of prostate. Its significance can genetic. This is the prostate is not important topic because it's very rare. And secondly, these are meant for specialist surgeons like urologists, not for undergraduates or for general practitioners, benign enlargement of prostate is very important. So I have put an asterix in front of that and then in part two will discuss about prostate cancer and a little bit about prostatitis. Why? Because prostatitis is very common, but it is often quite ignored and neglected by medical fraternity and anyone can come across these uh conditions and that's why you should know about it. Now, coming to the prostate itself, what is prostate prostate is a small walnut sized fibro gland alot muscular structure which is situated at the base of the urinary bladder. It is an accessory sex organ. It is not an urinary organ. It is an accessory such sex organ because urine passes through prostate, it can produce any pathology in relation to prostate can produce urinary problems. That's how it gets entangled with urinary system. Now changes in the problem. Now, there is no fixed size of prostate. It is highly variable, particularly if you're talking about 40 plus or 50 plus men, then it has got varying size. Roughly, you can say one year, one CC is a 20 year old will have a 20 CC prostate or less than that 30 30 CC, etcetera. But there is no standard size and you shouldn't feel surprised if you find a large prostate in a younger person. What are the functions of prostate prostate is important because it produces fluid. 40% of seminal fluid comes from prostate and it contains enzymes like P S A fibrin allies seen and it also contains prostate acid phosphatase. Um There is a protein course glycoprotein course perming is a hormone like substance which helps in motility of sperm. The other important endocrine function of prostate is that it converts testosterone into dihydrotestosterone. Dihydrotestosterone is 10 times more important than uh testosterone. And there are only three structures, three or four structures which convert testosterone into dihydrotestosterone. One is prostate. The other one is penis, penis, penile skin in particular and then the scalp. That's why you use dihydrotestosterone inhibitors in alopecia. People who are avoiding the use will, will, will talk about this later when we talk about prostate management, just a little bit about surgical anatomy of prostate, which relevant to clinical aspects. Now, if you look at prostate, this is the prostate here and this is the bladder. So it is situated just below the bladder and urethra is inside the prostate. So it is tubular structure here inside the prostate. And what do you see these are very important? These are neurovascular bundles which pass in the grow between prostate and rectum. This is rectum. So any disease and these become penal nerves, you know, cavernosal nerves here and cavernosal nerves are responsible for erectile function. So anything that affects the prostate and damages these nerves is likely to end up in erectile dysfunction. That's why this is important to know these structures. Now, here you see seminal vesicles and here you see vast difference. So vast difference comes like that and then it joins the seminal vesicle tube and then it becomes ejaculate dot And if you look at this diagram. This is completely split open between the rectum and the prostate. Now, there will be what is called as erectile urethral facia between these two that has been removed. Artificial diagram is mainly to understand the anatomy. And here you can see the prostate, posterior surface of the prostate and the neurovascular bundles. And this is the urethra and you can see the Detrol bladder muscle which is situated above the prostate and you can see the ureters going into the bladder. And here inside would be Trigon where the urethra will be the apex and two points will be the ureteric ends. Now, here you've got vast difference which crosses the ureter and then enters the seminal vesicle. And this is the anus, you can see this. So this is the surgical a nap. This is important for surgeons who operate on prostate. And it's also important to have a mental picture because when we talk about symptoms, you need to understand these pathological anatomy of the prostate. So that you understand how it is cause is because this is a very dynamic sort of subject where it is related to bladder and blood activity. That's why it's important. Now, this is the histology of prostate. You can see compound resumes, grants, which are which secrete prosthetic lee we were talking about. Then you have got a lot of Strama and you've got muscle as well. So this is the histology that's not again, very important from knowledge point. But you should have some mental picture. When we talk about various treatments, various aspects of prostate, you should know about it. Then we come across one important structure called pre prosthetics Pinter, which was called internal spincter in Ord anatomy books. Now, number eight, here is the pre prosthetic sprinter. Can you see this pre prosthetic sprinter? Now, what is the function of pre prosthetic sprinter? Pre prosthetics Pinter. Is it basically this situated between the bladder and the prostate as you can see and when the man is sexually excited or aroused, discloses pre prosthetic sprinter. Thereby cuts off urinary flow into the prostate and the urethra and this becomes totally a genital tract and it stops becoming being urinary tract, it becomes genital tract. So, semen ejaculate's ejaculated, semen passes through urethra like that. Now, the important thing about this is that it is supplied with sympathetic nerves. So whatever that upsets sympathetic, nervous, like emotional disturbances, sadness, anger frustration, they can actually affect distinct er and can cause contraction of this sprinter. The other thing you need to understand is this is a passive urinary passage. There is no valvular mechanism, prostate and bladder, they work together. So whenever the bladder contracts, this opens and the external sphincter here also opens, which is a voluntary sprinter and allows the urine to go out. But if you are stressed or if you are very, very worked up or emotionally disturbed, this is likely to close and urine can get trapped in this area. And it is possible that urine can reflux into the prostate causing prostate inflammation. We can, we can talk about this, you know, in prostatitis. So this is the mechanism. So that's why prostate is a very important structure. It is, it is very small. It is situated somewhere in the corner of the body, but it can cause lots of problems particularly the urine flow because it is situated just below the bladder. Now, there was a guy called John mcneil anatomist who did a lot of dissection about prostates and came out with a lot of meaningful anatomy of the prostate. Now, if you look at this, there's a very highly diagrammatic diagram and you have got pear shaped structure. It has got to um uh the, the vast going into that. And then this is the urethra. And if you look at your itra, it has got, this is the transition zone, transition zone is the one which enlarges in BPH and causes obstruction to the uh your itra. Whereas peripheral zone, which is here, peripheral zone is this one. And this one is responsible for prostate cancers. Most of the cancers occurring the peripheral zone. Why? Because those are the actively dividing glands, that's why you get cancer in this area transition area. BPH, benign enlargement of prostate. Now, the central zone is relatively intact and it can have prostate cancer. About 10 to 15% of cancers but it is mostly inert part of the gland, peripheral zone, 70% prostate cancers, transition zone, 10% prostate cancer. But rest, most of the times the transition zone is the one which surrounds the, your itra. But is also responsible for BPH. You don't have to remember this diagram. I put this diagram mainly for you to understand because when we talk about central zone, purple zone and transition zone, you need to have a mental picture how, how it is a very cruel picture. You don't need to have a very accurate picture that looks like this. Now, I will just to make a passing remark on congenital disease of the prostate, the congenital disease of the prostate and seminal vesicles go together because they're ducks are together, they become ejaculatory duct. So you can, you can talk about them together. These are very rare. Only one slide is enough for this. So sometimes you can have cysts in the prostate, you can have stones in the prostate. You can have poor development of prostate hyperplastic of the prostate. A genesis, sometimes there may not be any prostate policy. Now, these are rare conditions. You should always remember in medicine, rare conditions rarely occur and common conditions are commonly correct. So when you're talking about prostate, it is meaningful to talk about BPH about, about uh the prostate cancer. So there's no need to. So we'll pass on to benign enlargement of prostate. Now, the benign enlargement of the prostate has also got synonyms like being BPH, benign prostatic hyperplasia or hypotrophy. You can call any of these but commonly it is called as benign prosthetic hyperplasia. Now, it is not a simple thing that there is enlargement of the prostate and it leads to problems. There's a dynamics associated with BPH and it's important to know the dynamics of the BPH. Now, you know that prostate gland is the only internal organ in the human body which enlarges throughout the adulthood. Rest of the organs actually a crappy, they become smaller. But prostate is the one which flourishes and increase in size, irrespective of your ethnicity, race, creed, whatever it is it will keep and lodging. That's the important thing. Now, if you look at proportionate uh tissues in the prostate glandular tissue will be more than stromal tissue. Now, it causes lower urinary tract symptoms because it causes obstruction to the passage of urine in the apex of the bladder. So that's why people get urinary problems when prostate is enlarged. Not all patient's not all patient's with enlarged prostate will have lower urinary tract symptoms. We'll discuss that later. Now, you should also remember that at this age group, that means about the age of 50 60 etcetera. There, there is a problem with the detrusor as well, what are called as age related changes in the detrusor muscle. So, one of the main things that was found in bladders of aging people, both men and women was decreased number of neurons. You know, the nerve concentration is decreased in detrusor as people age. And that's why people get urinary symptoms, not necessarily because of enlarged prostate. What happens is that there is a normal understanding between prostate and the bladder and that may not work properly if there is a Detrol dysfunction, that's the importance of knowing that. Then polyuria. Now, polyuria due to various causes like diabetes or it may be due to drugs like diuretics, heart tablets, etcetera, they can cause polyuria and that can precipitate prostate like symptoms. So it's important to differentiate whether the person has got medical condition which has polyuria or whether he really has prostate problem, sleep disorders. Now you will be surprised to know that if you snore or if you have sleep apnea, you are likely to have some urine problems. Why? Because it disturbs ADH secretion from the pituitary, posterior pituitary. So people who have sleep problems, now, it is actually a interdependent thing because when you wake up and you want to pass urine because of sleep problem, you are likely to have disturbed sleep and and wise versa. So sleep disorders are very important cause of nocturia. So it's important to elicit that history. Then medical conditions, you know, heart failure, for example, can lead to edema of the legs. And then when the person lies down, that edema gets absorbed and the person will pass more urine in the supine position. So you may treat the person wrongly as a prostate patient. So it's important to carefully we'll discuss in the history when we come to that. But it's important to keep in mind that there are medical conditions which can actually produce nothing to do with prostate but can produce prostate like symptoms. Then many men, about the age of 40 actually have histological evidence of benign enlargement of prostate. That means there will be increased trauma, increased glands and muscular hypertrophy. So all these three elements could be present. Now, we come to etiology of BPH. Now why do people have enlarged prostate? That's the next thing. So 11 thing is there is a hyperplasia. We know that because the name itself suggests that there is hyperplasia, hyperplasia can occur because of cellular proliferation. That means the self increase in number. And it is also possible that there could be decreased cellular death. So, apoptosis, the natural cycle of uh death may actually decrease in these patient's. So there will be relatively increased number of cells, increased number of glands and increased number of you know, possible symptoms. So that's how it works. Now, then the role of androgens, particularly testosterone, dihydrotestosterone, as you know, testosterone is converted to Diadora testosterone in prostate and prostate is capable of producing these 10 times potent dihydrotestosterone. One of the problems with testosterone, estrogen and Diadora testosterone is that they act indirectly like growth factors because they actually affect their actions through cytokines and growth factors. And and this this can can be disparity. Now, the entrusting paradoxical situation is that androgen could be actually the sensitivity to androgen is actually decreased in older people. Why? Because of their relative low activity and it is physiological. So, angry gin receptors could increase in these people because less androgen uh combines with the receptors and then roll of estrogens comes into play. So if there are, if there are no, um if there's low testosterone, then what happens to estrogen estrogen a relatively increases. And animal experiments show that estrogens actually cause trauma will proliferation in prostate. And when there's stromal proliferation, stromal, you know, it's a missing caramel tissue, it actually increases the production of uh estrogens and thereby sorry, it increase the production of growth factors and cytokines which can actually lead to increased proliferation of cells. We have already discussed about apoptosis. I'm not going to deal with that, but I've just included it for uh for sake of understanding and stromal epithelial interaction. We have already discussed growth factors we have discussed and then genetic and familial conference. Now, it is possible that this could run inherited Torrey fashion because the cellular activity and cellular function is usually determined by genetics. So it is possible that people who have prosthetic problems can have male Children who can develop prostate problems later. Now, we'll look at the pathophysiology of BPH, you know why, what, how exactly prostate enlargement leads to various effects. We see various case presentations. We see now, as you know, there is a BPH, benign prostatic hyperplasia and then that causes immediate obstruction. Well, it doesn't cause immediate obstruction. It is not total obstruction either. It is a functional obstructions because the bladder is just imagine like a balloon and the neck of the balloon is like prostate. And if the balloon is, you're trying to let the balloon out against close outlet, then it is not likely to go because of resistance. And the same thing happens here. The bladder follows law pluses law, it increases in capacity. But at a particular point, it will increase the pressure and try to push the urine through the obstructed passage. And that may not happen. That's the main problem. So then detrusor becomes more active and it increases the pressure and it may increase the contractions. So that's why people may have urgency frequency and then you have a set of symptoms called us, lower urinary tract symptoms or also called us lots. So what happens is frequency, urgency hesitancy. All these are due to interaction between prostate and the bladder. Now, there are non BPH causes of obstruction as well. Like your little stricture, you can have bladder neck, narrow, bladder neck, they will also produce bladder outlet obstruction and they may be associated with prostate. In which case, the prostatic symptoms become very, um uh prominent. That's, that's the main problem. Now, in addition, to that because these patient's are elderly or older patient's, you are likely to see the effects of aging on the truce it so that can lead to death was the response. We have already seen that the nerve concentration is likely to be reduced in older patient's. So that can alter the date was the response. And then you can have neurogenic component. For example, if somebody has got diabetes associated with enlarged prostate, they will have additional problems with regard to directors the response and they might go into retention because the bladder may not be able to contract and overcome the resistance of the obstruction caused by the prostate. Then you have got bladder disorders like overactive bladder, which are completely independent of any other condition of the bladder or prostate. And they can suddenly become more prominent when the person has got even borderline of state enlargement. So the and and of course, we have already discussed about polyuria. So if you look at this particular chart, you see a very complex interaction between ureteral obstruction, detrusor function or dysfunction and urine production. So all these three things, three important factors, they work together and cause problems. Now, we'll look at natural history of untreated BPH. Now, if we don't treat BPH at all, what exactly happens in that patient. So the natural history of BPH is highly variable. For example, somebody who may start with very severe symptoms may actually get better over a period of time, maybe in 2 to 3 years, things might get better. Those are some, some patient's with very severe symptoms can get worse, get worse to such an extent that one day they develop retention of urine and will need hospital admission. So things can go wrong or things can go right as well. So the progression of BPH is variable from patient to patient. It depends on their nerve activity that cruise their activity. The amount of urine they produce the physical activity will, will discuss all those things in management. And they, these are the factors which determine the the symptoms. Now, progression is severe symptoms, which I have written here and plus or minus hematuria. So they can have blood in the urine because of high vascularity. And in which case, they will need full investigations. Again, we'll look at this later and then, you know, bladder dysfunction manifested by incomplete emptying of the bladder or they can manifest in unstable detrusor. Um And when the pressures are quite high, they can actually have urinary incontinence like urgent continence or even sometimes stress incontinence. But it all depends on various symptoms. You can't pinpoint a particular symptom in everyone. Then you can have more severe bladder outlet obstruction wherein you have, you, the person may go into acute retention or he can go into chronic retention or you can have even backpressure efforts. This is acute retention, which I have said acute on chronic retention. Let me just explain to you what is meant by acute on chronic retention saying that there we we are all born with one of the types of two types of bladder function. One is compliant, the other one is noncompliant. We belong to one of these categories compliant, bladders of those which actually work along with you. That means if you don't want to pay the bladder will accommodate that urine. Whereas noncompliant bladder sur those where in if you want to accumulate urine or if you want to accommodate some urine because you are talking to somebody or you are watching a movie or something like that, your bladder will not allow you to do that. It will say you have to go and empty now. So you have urge to pass urine and you will run to the toilet. Those are called non compliant bladder. Now compliant. Bladder's the problem with compliant bladder is that they can go into silent retention. And when they go into silent retention, patient's don't have symptoms at all and they come with quite late stages of obstruction, they can have hydronephrosis, they can have damaged kidneys, etcetera. The other important symptom in these patient's is that they pass urine, small amounts of urine normally. So they think that they don't have urine problems. But when even that amount of urine that is going normally is stopped, they're going to acute retention. That's what is called acute on chronic retention. So there is total obstruction. Do they urine flow? Then you have recurrent uti s. Now, one of the things you need to remember is why we don't get urinary infections. That's the question you need to ask why people don't get urinary infection even though they are exposed to bacteria. Because if you look at external matters, it is usually contaminated both in men and women. But still, then you don't get your urinary infection. That's because one of the main mechanisms of prevention of uti is the urine flow which is continuous. And when there's urine flow, there is static electricity, which actually doesn't allow the organisms to grow. But when the urine is test in stasis, when it is accumulated and undisturbed, the bacteria multiply and you get urinary infection and these are the patient's who will get urinary infection because their stasis and it can, they can easily have ascending infection and that can lead to your oh sepsis. Why do they get your oh sepsis? Because the resistance is not that great. When your kidneys are affected, for example, they're not emptying properly, they're unable to do their jobs properly. Then you are likely to have lower resistance and you're likely to get urosepsis. So that's the important thing you need to remember, then people can get blood stones. Uh You know, patient's if a 60 70 year old man comes with multiple blood stones, one of the things you need to think is silent, prosthetic obstruction, you may not be symptomatic, but there's a problem and there's a stasis. So you need to do full investigations before you treat the blood stones because he might need prostate treatment as well. Um, now we come to symptoms of BPH. Um, now, you know that, uh, previously, about 2030 years ago when people were studying, um, uh, doing research on enlargement of prostate, they used to follow what is called an international prospects symptoms score or IPSS, which was actually American in origin. And they used to have this kind of sheet. Now, it is commonly used in clinical practice because most of these clinics are run by nurses and they can easily actually mark these sheets or the patient's can mark these sheets themselves and you can actually have a degree of obstruction determined. For example, 0 to 7 is mild, 8 to 19 is moderate and 20 to 35 is severe. And I P S S not only predict, predicts progression, it also helps an outcome. For example, if you're treating the person with some medication, you can actually make out whether the person is responding or not. Now, I as a busy clinician, I don't go into all this. I depend on this simple um traditional old way of assessing like lower urinary tract symptoms. I divide them into obstructive and irritated symptoms, obstructive symptoms. It called frequency hesitancy, poor stream and incomplete voiding. Whereas irritated symptoms include urgency, urgent continence and frequency. So you can, you can go either way. So if the person has more irritated symptoms, that means he has got a lot of detrusor activity. If the person has got more obstructive symptoms, that means they're mostly in the form of prostate obstruction, but there is some compensation from the detrusor. So when you take his history inpatient, the first thing you need to do is obviously you need to allow the patient to tell whatever he wants to tell you. And you should listen to it particularly noting whether there's anything material, hematospermia, hematose, sperm E A means ejaculating blood in the semen and hematuria's blood in urine. This is we are talking only about visible immaterial, but we need to assess for indivisible him material as well. Then erectile dysfunction is important because anything you treat the prostate is likely to cause erectile dysfunction or erectile problems and you can get into unnecessary litigation. So it's important to get a proper history and assess and make a note of it. In New York notes, diabetes is very important. You need to ask for the history of diabetes, diabetes, mellitus as well as diabetes insipidus. Then renal disease, if the person could have renal disease when where there's polyuria and the prostate may be just the person is just blaming prostate, but actually the person may have a renal disease. So you need to investigate, take history in relation rails is heart failure, particularly, you know, you can just examine whether the, whether the person has got any peripheral edema or whether the person is breathless and then medications of course, are important sleep apnea, we have already discussed and that should be asked about. And then neurological conditions like Parkinson's throw spine issues and then medications which I have already alluded to beta blockers, anti hypertensives, anti cholinergics because all these can affect urine flow, urine output and bladder empty, then lifestyle, whether the person is said entry, whether the person has has active physical life and then fluid intake. Now this is very important. Now, you know that various trials on prostate have shown that those who do a lot of physical activity are less likely to have um prostate symptoms or they're, they're less likely to have uh the severity of the symptoms is reduced when the person is very active. Whereas couch potatoes, for example, people who spend most of their time watching TV, or not doing much activity are likely to have more severe symptoms. Fluid intake is very important. People may not drink enough water, they might drink only tea, coffee sometimes which can actually give very wrong impression about urine output. So you need to inquire about fluid intake. Emotional distress is very important because prostate is highly psychosomatic. As we saw, it has got alpha, our energy nerves and these nerves are easily affected by your mental balance. For example, if you are upset, the the spin trees likely to contract and can access er bait symptoms. So it's important to understand that. Now, once we have seen this, now we'll go for the examination patient. Now, obviously, the, the thing I would like you to remember is what the Great Osler said. William Osler, who used to be professor of medicine in Oxford, he said, abdomen extends from nipple to nice. That means when you're examining the abdomen, you know, completely undressed from nipples to knees, so that you are able to examine the genitalia in men. And also to see whether the person has got any breast disorder. So it's very important to examine properly and in particular, the blood or palpable bladder and also general assessment particularly should take BP and you should also check for peripheral edema and also congestive cardiac failure. Then gentle leah, you should examine for external meters, um fimosis and you know any other condition, there may be meatal stenosis, there may be fimosis, there may be some problem with, with external matters. So simple examination will give you a lot of information. Then you should examine the testes or tenderness. Because sometimes when people have very severe urinary tract symptoms, they can have pain in the testicles because of reflux of urine into the testes. And also whether the person has got hernia, hernias might have come recently because of obstruction and straining of the case. So it tells you the severity of symptoms, then rectal examination. Now, before being rectal examination is important. Of course, before being examination, you need to take verbal consent and you need to ask the patient whether he or she wants a chaperone. In this case, he always. So we say we, you know, we ask whether the person wants a chaperone if he says no, he does not want the spine. But verbal consent is important and should be made not in your notes and rectal examination. When you write rectal examination, you need to explain the purpose of examination why you are doing rectal examination. What are the likely findings you might get? So that's the important thing. Now, obviously, rectal examination in this case is to assess the baseline prostate volume and ruler that signals prostate cancer. And the third one is anal tone. Now, traditionally, in this country in the UK, we examined the patient left like push in, but you can also examine the patient in need just position. Now, the findings are likely to be the consistency of the prostate size of the prostate. These are all very crude uh findings, but they are important because they become baseline for future comparison, tenderness, your it'll discharge and any rectal lesion, you will be surprised. I have detected three rectal carcinoma hours in my whole career by just examining the rectal exam, doing a uh rectal examination because I was I I thought that the person has something else and these people had rectal papillomas, rectal tumor's and so on. And so forth. So once you have done all this, then the next thing is investigations, you could broadly classify um, investigations into laboratory investigations and you know, attract investigations, say laboratory investigations, you do midstream urine, urine analysis, renal function assessment, prostate specific condition and additional tests as you require. For example, if you think the patient has got jaundice, you need to do LFTs. If the person has, it looks any make, you should do full blood count and so on and so forth. So it is variable. With regard to urinary tract, you need to do frequency volume charting and bladder diaries. Now, that's a very simple which is cost effective. It doesn't cost anything. You just give the chart to the patient to fill it in and you will be able to understand the functional blood capacity for that patient. Also sound of urinary tract and uroflowmetry. It's called as ultrasound euro dynamo Graham. And that, that gives you a very good idea about whether the patient is able able to empty the bladder and also the type of local you can't uro dynamics is not needed in every patient. But whenever the patient is very young, like in their early forties and come with prosthetic problems and you have ruled out all of the conditions, then uro dynamics might be necessary and flexible cystoscopy to uh to assess medium law because median lobes can only be diagnosed by having look inside the bladder and the prostate so that those are the investigation, I'm just going a little bit fast because we need some time for questions. So uh now we go to management of BPH. Now, before you get into the uh thinking about um uh management of BPH, you need to make sure that there are no complicating conditions associated with BPH. One of them, I mean, one of them is hematuria. Then UTI S raised PSN neurological problems, complicating blood and you're a train or any other systemic condition. Now, why hematuria is important? Now, the BPH can also cause hematuria. Prostate cancer can cause hematuria and bladder tumor can cause hematuria and kidney tumors can cause image. So there may be associated conditions, you know, the person may have BPH, but he may have a kidney tumor and or he may have a blood tumor. So you shouldn't assume that he materials because of BPH, I just leave it. You should do a proper C T I V U like protocol dictates. You should do C T I V U and cystoscopy, proper cystoscopy for hematuria. I mean flexible cystoscopy. If he's not bleeding, if he's bleeding, then you will have to do rigid cystoscopy under anesthetic UTI S. If the person has got UTI S again, you have to do proper investigation. There may be associated conditions like stones or congenital anomalies. So they should be ruled out. Now, raised PS A straight away, you think about prostate cancer but you should remember that PS PSA is not, is not cancer specific, it is prostate specific. So whenever there is raised, PS PSA, all that indicates is that PSA is leaking from the prostate into the systemic circulation. So there is damage to the prostate. So BPH itself can cause raised PS A prostate cancer can cause P H A P raise the PS A, any hemorrhage inside of the prostate can cause PS A, any stress can cause raised PS A. So you should be aware of that, but at the same time, you shouldn't be naive and leave it thinking that oh, it is because of enlarged prostate or something like that. Neurological disorders. One of the first manifestations of neurological disorders could be urinary symptoms. So particularly multiple sclerosis and and various other diabetic neuropathy. So you should, you should have a proper assessment by neurologist or whoever is concerned with that particular system and any other systemic conditions. You know, sometimes you have um bladder tumor infiltrating the prostate which can cause problems. Um and also various other diseases like spinal cord metastases can lead to urinary problems. So in a 70 year old man, if you have suddenly unexplained urinary symptoms due to something different, then you should keep your mind open and investigate. According. Now the prostate can be treated, be benign, prostate can be treated for mild cases. You could do watchful waiting. That means you advise on lifestyle, educate the patient about diet and exercise, physical activity and periodic monitoring of the symptoms and make sure that the prosthetic pathology is remaining constant and not becoming, you know, is not increasing in severity. So then you know that washed will waiting be ideal. Now, medical therapy, you can actually give alpha adrenergic blocking medications, which we have discussed that alpha-adrenergic nerves are there in the pre prostatic sprinters. So you can actually block these no serves by giving drugs and that can actually relax the prostate and allow the urination to occur and then fire alpha reductase inhibitors. File for reductive is the enzyme which converts testosterone into Diadora testosterone. So you can actually give this as well. And then antimuscarinic agents like uh to relax the bladder if they have increased blood irritability, PDI PDE five inhibitors. These are like Wagga, you know, Sildenafil Tadalafil, these are also helpful in prostate problems. So if the person has got erectile dysfunction and prosthetic problem, you can actually consider giving PD five inhibitors, then you have got horrible drugs like saw palmetto and various other medicines. But these are not, I've just included them for uh for completion sake. But some, some countries like for example, Germany horrible medications are quite popular. Now, alpha-adrenergic, I just want to touch upon alpha adrenergic medications. Now, as you can see, it's a beautiful diagram here about the pre Prostatic Sprinter. This is the prostate and this is external spincter. Now, when you give alpha-adrenergic blocking drugs this spincter is relaxed and when this is relax, the prostate is relaxed and the urine flows easily. So that is the mechanism of alpha adrenergic medications. So you've got various drugs but mainly tamsulosin and offices in are the most popular drugs. Now, with regard to alpha reductase inhibitors have already explained to you that testosterone is converted dhd. And by actually blocking, because prostate is sensitive to dhd, it is not sensitive to testosterone. So by blocking this conversion, you can actually shrink the prostate. That means you can actually reduce the hyperplastic tissue. Um Now, as you know, it is also used in hair loss because here scalp has got capability of uh converting testosterone to dihydrotestosterone which is responsible for mary type of boldness. So, but the only thing is the dosage is 1 mg. Whereas in, in when you give, finish, tried in, in for prostate, we define milligram and you also got your test ride, which is type one and type two receptor blocking drugs. So that is enough about this because there's no need to go into the details. Then there are. So when do you intervene in a patient who has uh prostate BPH? So absolute indications include acute urinary retention, frequently, material recurrent uti s and chronic urinary retention. But the important thing is you need to assess any patient can undergo surgical intervention, but it has to be carefully assessed and only when it is necessary to understand that surgical treatment is a must, then only should be considered. Now, we have got number of treatments available for surgical procedures for prostate obstruction, trans urethral resection where you actually the basically the principle is to reduce the amount of prosthetic tissue, which is obstructing the urinary flow and court. It is basic plumbing, basically is plumbing in the sense that you actually court the prostate and remove the central part of the prostate so that the passages increase. So you can do that by transferred through the section where you actually cut. This is the world desk type of or just mode of treatment which has stood the test of time and is still used. And there are lots of modifications which is not necessary for you to know. Basically it is done as an inpatient procedure. Prostate autumn eu just make an incision in the prostate. Uh for a very large prostate. You can do open or robotic simple prostatectomy, laser prostatectomy can do laser resection aqua ablation where you use hot water and then tuna transurethral needle ablation, use needle to call the whole transfer little incision of prostate, which is similar to prostate otta me. But with special equipment, embolization, you can actually embolize the prosthetic vessels and thereby you can cause infection of the prospect microwave therapy itself suggest what it said. You cook the prostate and register volume vaporization. You, you actually vaporize the prostate with heat and then the prosthetic units will lift you actually put the stitches to retract the lobes of the prostate and thereby widen the passage. So these are in brief of our surgical procedures. Thank you very much. And now we got questions and answers. Yes, professor is a student asking do patient, do patient's can have any problems with prostate if he's taken finance to drive 1 mg from a year or two. No, you shouldn't take 1 mg. That's not effective for prostate. You need to take 5 mg. That's the number one, number 21 of the problems with Finasteride is it can mask PS PSA. So if a person is taking finesse, tried and he comes with the raised PS A, you have to double the PS psa I will explain this. Let's say that you have got a patient who is 67 has been taking finish tried for two years and then he comes to see you and his B S A is four. Now, actually his B S A is eight if he's taking Finasteride, so he should be investigated. That's what him. Hello? Yes, we can, we can hear you professor. Yeah. Okay. Any other question? Can you just explain? How do you uh anal tone? Will you do? Anal tone is? Yeah. The first and the foremost thing is to make the patient relax and you have to explain and talking is very important. You shouldn't straight away, make the patient lie down and straight away. Put the finger in. So one of the worst way of examining uh and when you enter the anal region, you actually the sprinter contracts, but then the patient relaxes it. Now, if that reflects is there, that means the anal tone is norm. Okay. Okay. Thank you. Any other questions? Um Hi, doctor. Is it always necessary to um do uh rectum examination in all uh male patient coming with uh any uh possible uh you know, uh um for no problem. No, not every patient allergy problem. Sorry, I mean, urology know if somebody is coming with lower urinary tract symptoms, okay. And if you have focused on prostate, you think that the problem is coming from prostate, then you should examine the prostate. There is a saying in surgery, if you do not put your finger in the rectum, you are likely to put your foot in it in the future. That means you have, you, you can make mistake by not examining plastic. So it is always imperative. If somebody is 67 or 60 year old man comes with urinary problems, I will, I will definitely do rectal examination. But as if somebody say, um, someone who is 25 has come with urinary symptoms, lower urinary tract symptoms, but complaints about pain while passing urine or burning mature ation, you should do a rectal examination. Why? Because he may have prostatitis and the only way to exactly diagnose in some cases would be rectal examined because it will be tender. You have to use your reasoning why? Because you need to justify to the patient, why you want to do the examination. And that itself will give you guidance, whether you should do the examination or not. That's what I told you that you should, you need to explain to the patient about the purpose of the examination. Next. Got 10 more minutes. Hmm. There's a student asking doctor if the patient comes with an I P S A and then what should we do is in the only stage of cancer? No, it is not. I told you that PSA is prostate specific, it's not prostate cancer specific. So obviously, if a person comes with high P S A, the first thing obviously is to repeat it after some time, usually of 3 to 4 weeks and if it is persistently high, then you need to, you need to proceed to the further assessment. Uh We'll discuss this in the next lecture. But basically that person, that patient will need MRI multi parametric, MRI, you should never tell the patient that this is an early sign of cancer and I'm going to investigate you. That's the wrong thing to say what you tell them is that your blood test has come back slightly abnormal. I want to check it, make sure that it is that that it is high all the time. And you should also ask relevant history and then if the history and because history may not give you anything in these cases. I mean, completely silent. And in which case, then you do the rectal examination, you find an audio or hard area in the prostate. Then obviously you need to go further and investigate the patient for um MRI multi parametric camera. Next. Any other question? We got four minutes left. We've got still time so you can ask questions. Please don't ask anything, don't worry about it. Yeah. There's nothing called silly question or anything. Every question is important in a classroom. Every question is important and every answer is it should be analyzed. Um Yes, hi doctor. Um So once you have a patient that was the P S A, it's abnormal and you, you are a bit concerned. How often do you repeat that examines every six weeks or 12 weeks or three months or what is the half life of PS A? Sorry. What's the half life of PS day? I don't know. Doctor. Yeah, that, that's, that's the important, that's the answer for your question. Half life of PS PSA is about three weeks, three weeks. So you need to repeat it between three and four weeks and, and if, because P S A can be, you know, for example, as I told you, it's because of leakage of PS A into the bloodstream. So if there is a problem and that has been, that has been sorted out, the PS PSA will start falling and then you need to check whether the PS PSA is. Um, now we'll discuss quite a, quite in detail in part to when we talk about prostate cancer, we'll discuss more about P S A. Otherwise it will take the, uh the, the important points out of that lecture. But if it is normal for how, how long do you discharge the patient afterwards? Or do you still monitor them? Either way, what we do here is once it comes back to normal, we discharge them back to their GPS and they monitor them probably every for a couple of couple of times every three months. And then if it remains normal, then you, you, you, you, you can do once a year because here in this country, anyone about the age of 60 can help. Yes, it and in fact, anyone can help. Yes, it and if they are worried about prostate chickens, lovely. Thanks so much MS Doctor Assad has a question. You can ask your question, sir. Yes, so that we can hear you can ask your question. Please ask question. I can't hear you. You need to, you can type it on the screen. Uh type it on the screen because I can't hear you what you're saying. Okay, while he's waiting. I've got question doctor. So you mentioned one of the symptoms of um BP H was immaterial, a counselor or immature really uh as one of the symptoms yet, it's not one of the victims. No, I didn't say that. I said it's one of the complicating factors. Oh, okay. All right. Uh Sorry. Okay. Complicated factors of uh BPH uh immaterial. I've been thinking, how would, how would that cause immaterial? I mean, how does that lead to immaterial? Well, because what happens in then, then why does the, when there is enlargement of the prostate, there are certain things that happen with it. One of them is increased vascularity. What is the difference between normal vessels and neovascularization? Question for you different between the normal basis and uh vascularies ation. So I'm guessing the new vascular disease um will not be as strong as they, when you say strong. What do you mean by that? You are, you are supposed to be, you're going to become a doctor. So you need to talk more precisely. Sorry, I'm just teasing you. That's good. Um So I mean, okay, I will answer this question. Don't okay. So in normal vessels, you've got muscles whereas in new vessels, you are not only endothelium. So these vessels are quite, you know, they will be easily ruptured or they will be easily. Therefore, they're, they're easily damage herbal. So, urine, urine, they come in contact with urine, they come in contact with pressure's so they can easily rupture and when they rupture you pass blood. Yeah, I think that's what I was trying to explain, but you explain it better. That's what we buy uh weaker but Thank you for explaining that any other question? Yes. Can you hear me now? Professor? Uh one of my and asked me professors in first year in a joking manner, asked a question that how do you check that, that your prostate is uh working or? Right? Like it's a self check manner. And he, he just said to one of my friends to whom he asked the question, you just uh stimulate yourself. But is it a proper way to tell a patient or someone who is concerned about the prospect too? Look the thing about prostate. If, if you know you, you, that's the uh if the, the only way to diagnose because there are two organs here, seminal vesicle. Uh If the main thing is here, seminal fluid, that's the diagnostic that you have got all normal accessory structures. Okay. Now, 60% of the fluid that you ejaculate comes from seminal vesicles, 40% comes with if it comes from prostate and very little comes from testis, which is mainly containing uh sperm. Now, if the volume ejaculatory volume is reduced, then there may be obstruction to the prostate or there may be enlargement of the prostate. But most of the times you don't go looking for whether that this person has got prostate or not, because that's a very rare phenomenon that your prostate is absent is a very rare thing. As I told you, a place of the prostate is extremely rare and rare things are rarely correct in medicine. So you should be very careful when you talk like this. So the main thing about this is if you want to really know about prostate, then you have to do investigations, you have to actually do emerging of the prostate. And the simplest investigation is otozin transrectal ultrasound of the prostate. You put the probe inside the rectum and you will be able to see the whole of prostate. That's how I would answer. Not like uh I'm not, no, no with no disrespect to anybody by the way. But if you are asked an exam, how do you check for prostate? One is by rectal examination and the second one is by emergently. Thank you, sir. Okay. Any other question or it's already for? Yeah, go on. What is more accurate though the, the ultrasound or the examination? There, there are two different things and you know, uh ultrasound is useful for anatomy of the prostate. Okay. It won't tell you where the cancer is, it won't tell you where the abnormality is because you feel the enlargement. Yeah. No, no, no, no, no, no, listen to them. Whereas MRI will tell you differential appearance of prostate or for various conditions. So, MRI is more accurate when you are talking about pathology, enlargement of prostate is irrelevant. Actually, it is only a, it's only a description. Does that affect the symptoms? No, it doesn't. The amount of prostate that is present inside the, your itra is the one that determines the symptoms, not the size of the prostate. We often see very large prostates but no symptoms. Whereas some patient's have got very small prostate, but they have got very severe symptoms. Why? Because the, your itra is occupied by the prostate. That's why they have symptoms. Yes. Any other questions? Do we have any other questions? Uh No, thank you. Okay. I hope it was useful for you. And, you know, we'll, we'll, we'll talk about prostate cancer in the next one. And I will also add a little bit about prostatitis because you should know about prostate, how to recognize you. And if possible, read a little bit about prostate cancer, whatever you can understand. And we'll discuss more about P S A and various other things. As far as the symptoms are concerned, prosthetic canceled, there aren't any specific symptoms. There could be BPH symptoms as well. So we don't discuss much about that, but we discuss about diagnosis and management. All right. All right. Thank you very much doctor. It was a very amazing lecture. I thank everyone who attended as well. If, uh, if I