REMEMBERING PROF. K.M. SINGH BY HIS LECTURE ON BENIGN HYPERPLASIA OF PROSTATE

 

 

Prof. K.M. Singh was a Reader in the Department of Surgery, in King George’s Medical College when we were doing our MBBS. He always wore white clothes and a starched apron and was responsible for the teaching of undergraduate students along with Prof. T.C. Goel. He was always smiling and very helpful and was easily approachable. We could go inside his room with any problem and he was always keen to help. He lived in New Hyderabad, almost 3 Km from our Institution and was extremely punctual. His classes were very methodical and they were very easy to follow. For those who found English difficult to grasp, he would translate in Hindi and repeat the subject again and again till the last person had understood the point. This quality made him very popular with the students.

 

During our residency days, posting in his unit was most sought after because of two reasons – he would see to it that surgery was fairly distributed amongst residents and he had started doing cystoscopy and trans urethral resection of prostate for benign hyperplasia of prostate (BHP) and urinary bladder tumours (BT). The urinary bladder endoscopy was newly introduced in the department and only Prof. Harish Chandra and Prof. K.M. Singh were performing it and all residents were keen to learn the skill.

 

An outstanding quality of Prof. K.M. Singh was his respect for his seniors and colleagues. During my residency days, when I was a resident in Prof. R.P. Sahi’s unit, one day I saw Prof. K.M. Singh waiting outside Prof. Sahi’s outpatient clinic, where he was teaching undergraduates. When I asked him that should I inform Prof. Sahi that he is waiting outside he, most vehemently, said no, and waited for the next 45 minutes patiently. Any other staff member of his seniority could have excused himself and barged in, but for Prof. K.M. Singh that was simply unthinkable. His respect for his seniors was only matched by his love for his students. These enviable qualities and his professional skills took him to the post of Head of the Department of Surgery and eventually the Principal of King George’s Medical College.

 

Prof. K.M. Singh had h huge collection of surgical instruments, X. rays and pathology specimens in his room and they were routinely used for undergraduate teaching. I was one of the few residents who could borrow them for my evening ward teaching of students and next day he would always ask how the class went.

 

After returning from my overseas training I started practicing in Mahanagar. My new clinic was bang opposite Mahanagar Nursing Home and Prof. K.M. Singh would operate his private patients in that hospital. He always wondered why I spent all the money in buying a clinic when I could easily practice from his chamber in the morning when he was in the Medical College. On countless occasions he would send a ward boy to call me to assist him in his surgeries. One day when I referred a patient of acute appendicitis to him he got really angry “Why can’t you operate on appendicitis?” he enquired. I told him that I will only do Plastic Surgery but he was not convinced. “You cannot refuse to operate when you can, it sends wrong message to the society”. He made me operate on that patient that evening and never entered the OT. He later shifted to a bigger and better hospital but his affection for me never waned and he referred all his plastic surgery cases to me.

 

This is an undergraduate lesson on Benign Hyperplasia Prostate that was taught to our class by Prof. K.M. Singh.

Epidemiology

BPH is common with incidence increasing with advancing age. Whilst rare before the age of 40, it affects 30-40% of men older than 50. It is seen in around 90% of men aged 90. Men of African origin are more commonly affected.

Aetiology

The aetiology of BPH is poorly understood. BPH is common with increasing age. It is a hormone-dependent process involving testosterone and dihydrotestosterone production. A failure of normal apoptosis and abnormal epithelial and stromal proliferation have been implicated. This proliferation occurs primarily in the transition zone of the prostate, this leads to restriction of the prostatic urethra and urinary flow.

Clinical features

Features tend to be those of increased urinary frequency, nocturia and incomplete emptying.

• Urinary frequency
• Nocturia
• Incomplete emptying
• Decreased urinary flow
• Dribbling
• Hesitancy
• Retention (acute or chronic)

This condition can cause bothersome problems including frequent urination at night, as well as difficulty completely emptying the bladder, and the urgent need to urinate at inconvenient times. BPH triggers noticeable problems in a third of men in their 60s and nearly half of those in their 80s. In the case of men with milder symptoms, BPH may not interfere with their daily lives much, but if it gets distressing and interferes with quality of life then surgery may be required.

Irritative symptoms (problems with bladder function) include:

• Frequent urination during the day or night
• Strong and sudden urge to urinate, sometimes with involuntary leaking of urine
• Obstructive symptoms (problems with the flow of urine) include:
• Difficulty starting urination
• Straining to urinate
• Incomplete bladder emptying
• Weak or intermittent urine stream
• Dribbling after urination.

Patho-physiology

The prostate gland may begin to grow larger over time in many men. The urethra passes right through the prostate, so it doesn't take much prostate growth to make urination difficult. It is usually the median lobe which obstructs the flow of urine. As the bladder works against the restriction, its muscular walls begin to thicken which can cause problems like the need for more frequent visits to the bathroom and difficulty fully emptying the bladder.

Examination

Digital rectal examination

This is a key component of the examination and allows for assessment of the rough size of the prostate. Irregular enlargement should raise concerns and further investigation for cancer. Evidence of reduced anal tone may be indicative of neurogenic causes of lower urinary track symptoms.

Investigations

Investigations are targeted at confirming the diagnosis, excluding malignancy and accessing for complications.

Urinary

Routine and Microscopic examination of urine is advised. Under the microscope we look for casts, RBCs and pus cells.

Blood

• General Blood Picture
• Blood urea and Serum Creatininr
• Blood Sugar – fasting and post prandial
• LFTs (Alkaline Phosphtase may be elevated in prostatic cancer with bony metastasis)

Additional investigations

Depending on the differentials and certainty of diagnosis, there are many other investigations that may be ordered. These include voiding cysto-urethrogram, urethrocystoscopy and urodynamics (e.g. filling cystometry and pressure-flow studies).

Management

Management is aimed at reducing symptoms and preventing complications (e.g. urinary retention and infection).

Conservative, medical and surgical methods may be used to treat BPH.

Conservative

Consider watchful waiting in those with mild disease and symptoms. Surgery has complications that may be avoided or delayed. In certain circumstances, when patient is not fit for surgery, a long-term catheter (changed every 3 months) is used for management.

Fluid restriction: Patients are advised to restrict the volume of fluids they drink and when they drink to prevent bothersome bathroom visits. Advise them not to drink fluids before driving, traveling or attending events where finding a bathroom will be difficult. Also, ask them to avoid caffeine and alcoholic beverages after dinner or within two hours of bedtime.

Bladder habits : Ask your patients to change the time and manner in which they empty their bladder to reduce symptoms or make them less disruptive.

• Caution them not to hold it in for too long.
• Ask them to empty your bladder when they first get the urge to do so. 
• When out in public, ask them to go to the bathroom and try to urinate when they get the chance, even if they don't feel the need.
• They should take your time when urinating, emptying their bladder as much as possible.
• After each time they urinate, they should try again right away. 
• They should try urethral milking, this will prevent post-void dribbling. 
• Teach them to gently squeeze the base of the penis after urinating and work their way outward to force urine out of the urethra.

Medical

Treatment of urinary track infection – but this may be virtually impossible if the prostate is causing outflow obstruction. Stagnant urine has a tendency to get infected.

Surgical

Transurethral Resection of the Prostate (TURP): is a new procedure in which a resectoscope is used to resect obstructing tissue. There are a number of complications that can occur. Retrograde ejaculation (up to 75%), urinary infection, need for urinary catheter are all relatively common. Occasionally clot retention, urinary incontinence, urethral stricture and erectile dysfunction may occur. A rare but serious early complication is TURP syndrome.

Open prostatectomy: tends to be reserved for very large prostates (> 80-100ml) following discussion of more conservative options. No ejaculate can be produced following prostatectomy and most experience symptoms of urinary urgency, frequency and nocturia. Erectile dysfunction may occur. Prostatic tissue remains and cancer can still occur.

Treatment of Urinary retention

Urinary retention may complicate BPH

Acute retention

Men presenting with acute urinary retention require catheterization. Ensure you evaluate for infection and renal impairment that may complicate urinary retention.

Patients require urological review and work-up (particularly if they do not have an existing diagnosis). Typically on the first occasion, a patient may be catheterized. Recurrent retention typically indicates a need for surgical intervention.

Chronic retention

Men with chronic retention should be catheterized particularly where there is renal impairment or hydronephrosis. Often surgery will be advised, though intermittent self-catheterization or a long-term catheter can be used to tide over a critical phase.

 

That is how Prof. K.M. Singh’s lecture on BHP ended. Those were the days when there were no Ultrasound and MRI, no Uroflowmetry, no drugs like alpha blockers, 5-alpha reductase inhibitors, or tadalafil, which can relax the bladder neck and prostate, shrink the prostate, or improve the urinary flow and those were the days when suprapubic open prostatectomy was commonly done. Under these circumstances when I look at my class notes, I can only wonder how conclusive our undergraduate teaching was and how much effort our teachers like Prof. K.M. Singh took to teach us.