良性前列腺增生英文课件

TheProstateandBenignProstaticHyperplasiaAccessorySexGlands•Prostate•Seminalvesicles•Cowper’sglandsWeWillConsider•Thestructureoftheprostateanditsroleincontinence•Themechanismofejaculationandtheroleoftheprostaticinnervation•TheroleofthesecretoryproductsoftheprostateintheprostaticfluidTheStructureoftheProstateMcNeal’sHypothesis•Transitionalzone–thesiteoforiginofBPH•Centralzone–Wolffianductorigincfvasaandseminalvesicles•Peripheralzone–thesiteoforiginof75%ofcancers•AnteriorfibromuscularstromaOrigin•Peripheralandcentralzones-UGsinusDHT•Centralzone–WolffianductsTestosteroneOriginofCirculatingTestosteroneTestosteroneUptakeDevelopmentoftheProstate•DHTformedmainlyinepithelialcells•DHTdiffusestostroma(mostoftheandrogenreceptors)•Stromalnucleiproducegrowthfactors•GrowthfactorsdriveepithelialcellsStromal–epithelialinteractionSummaryGrowthFactorsNormallybFGFEGFTGFα20%TGFβinhibitory80%stimulatoryThePre-prostaticSphincterProstaticInnervationClassical•adrenergic•cholinergicNANC•5-HT•Dopamine-β-hydroxylase•VIP•NPY•Leu-encephalin•Met-encephalin•CGRP•SustancePAlphaAdrenergicInnervationα-adrenergicreceptors–98%instroma•alpha-190%•alpha-210%alpha1a–60%Innervation•Cholinergic-epithelialsecretion•Adrenergic-smoothmusclecontraction•Neuroendocrinecells-serotonincalcitoninTSHsomatostatin-regulationofsecretion,cellgrowth•NANC-?BladderNeckvPreprostaticSphincterBladderNeckBothsexesAtbladderneckCholinergicinnervationContinencemechanismPreprostaticsphincterMalesSupraverumontanalAdrenergicinnervationGenitalsphincterEjaculation-Mechanism•Spermatozoaandprostaticfluid,thenseminalvesiclefluid=Emission•Antegradedespitecompetenturethralmechanism•VoidingdifficultwithanerectionandimmediatelyafterejaculationBladderNeckTightens–U/SUrethralPressureProfileEjaculationSequence•Bladdernecktightens•Emissionofvasalampullarysperm•Contractionofbulbospongiosus•Contractionofprostaticsmoothmuscle•Urethralsphinctermechanismovercome•FurthercontractionofprostateandseminalvesiclecontractionSeminalPlasma2mlseminalvesiclesecretion0.5mlprostaticsecretion0.1mlCowper,sglandsandglandsofLittréRoleofSeminalPlasmaOptimisefertilisation•(ejaculatedspermvaspiratedsperm)•protectiveeffect•enhancemotilityandsurvivaldirectlyProtectiveeffectonurinarytract•biologicalesp.Zn,spermine,Ig•mechanicalwashingLubricationProstaticSecretionProteinsAcidphosphatasePSALeucineaminopeptidaseDiamineoxidaseΒGlucuronidasePlasminogenactivatorComplementC3andC4Transferrin,transferritinGrowthfactorsAnnexin1NonproteinsCitrateSpermineSpermidinePutrescineZincMyoinositolCholesterolFunctions•Zinc-4°structureofspermchromatin•PSA–semenliquefaction•Otherwise?Non-ProteinsCitrate240-1300timesconcentrationelsewhereZincPolyaminesExistasacomplextomaintainelectrochemicalneutralityalsoinuniquelyhighconcentrationsBenignProstaticHyperplasiaBPH-MisconceptionsGeneraliseddiseaseoftheprostateduetohormonalderangementwhichleadstoenlargementoftheglandwhichcausescompressionoftheurethraleadingtosymptomsAetiology•Age•Functioningtestes•ProstatenormaltobeginwithPossiblyaseriesofgenetic‘hits’which,withfurther‘hits’,willleadtocancerOtherFactors•Racial-americanblacksvorientals•Dietary-yellowvegetables,westerndietPathogenesisAndrogens-permissiveStromal–epithelialinteraction•normal2:1,BPH3or4:1•majorchangeisconnectivetissueStromal-EpithelialRatioinBPHEpithelium25%+/-Stroma75%+/--connectivetissue50%+/--smoothmuscle25%+/-Pathogenesis-2Micronodules:transitionzonelaterallymicronodulesinperiurethralzoneposteriorlyPathogenesis-3TransitionzoneenlargeslaterallyoneachsidestromaandepitheliumPeriurethralzoneenlargesposteriorlystromaonlyfiroblaststransformingtosmoothmusclecells‘embryonicreawakening’HistologyPosteriorLateralAndrogensandBPH•Permissive–invivoandinvitro•GrowthfactorsarejustasimportantGrowthFactorsandtheProstateNormalbFGFEGFstimulatoryTGFαTGFβ-inhibitoryGrowthFactorsandtheProstateBPHbFGFstromalautocrinestimulatoryKGFstromalparacrinestimulatoryTGFβ1stromalautocrine/paracrineinhibitoryTGFβ2epithelialautocrine/paracrineinhibitoryIGFstromalparacrinestimulatoryGrowthFactorsandtheProstate?TGFβupregulatedbydecliningserumtestosteronewhichthensecondarilyaffectsothergrowthfactors?lifelongejaculation/voidingaffectingthe‘bend’AgeingBPHDetrusorinstabilityImpaireddetrusorcontractileefficiencySymptomaticBPH•BPHalone•BPHplusdetrusorinstability•BPHplusimpaireddetrusorcontractility•BPHplusDIplusIDC•IDCwithoutBPHintheelderly•IDCplusDIwithoutBPHintheelderlyUrodynamicAspectsofBPH•agerelateddeclineinurinaryflowrate•agerelatedincreaseindetrusorinstability•outflowobstructionOutflowObstruction•Obstructionisapressure-flowphenomenon•PressureistheprimarydeterminantQuestions1.WhatarethesymptomsofBPHalone?2.HowdoesBPHcauseobstruction?3.Doestheobstructedbladderdecompensate?4.Whatisthecauseofacuteretention?