11. Benign Prostatic Hyperplasia Flashcards
What is the acronym FUN WISE?
LUTS
- Frequency
- Urgency
- Nocturia
- Weak Stream
- Intermittency
- Straining
- Emptying Incompletely
What is the IPSS?
International Prostate Symptom Score:
8 Question Swritten screening tool to screen/diagnose LUTS for BPH
- 20-35 = Severely symptomatic
What are the short term consequences of BPH progression?
- Pain
- Financial Cost
Recurrent Hospitalisation
What are the long term consequences of BPH progression?
- Likelihood of subsequent surgery
- Increased risk of complications vs elective procedures
- Risk of recurrent retention
*What are the NICE 10 Key Priorities for Implementation with regards to LUTS
- If LUTS, assess their PMH to identify causes of LUTS/comorbidities
- Offer men a Physical Exam/Abdo Exam/Genital Exam/DRE
- Complete Frequency Volume Chart
- Refer for specialist assessment if there is Recurrent/Persistent UTI
- Give them care for Physical/Emotional/Psycho/Sexual/Social Needs
- Storage LUTS need advice for relevant support groups
In regards to LUTS, give 4 examples of Filling/Storage Symptoms
- More Frequency of urination
- More Urgency of urination
- Nocturia
- Urge incontinence (Loss of bladder control)
In regards to LUTS, give 4 examples of Voiding Symptoms
- Weak/Intermittent Stream
- Straining
- Hesitancy
- Incomplete emptying
For those with LUTS, what is the NICE Recommendation for Initial Assessment?
- Assess GMH and Review of Medication
- Focused Physical Exam
- Abdo/Ext Genital/Digital Rectal Exam
What Investigations can you offer for those with LUTS
- Urine Dipstick
- Frequency Volume chart (For problematic LUTS)
- PSA Test: Advice and Time if their LUTS suggests Bladder Outlet Obstruction secondary to BPE
- Serum Creatinine
- Treatment
What is the Frequency Volume chart?
“Bladder Diary”
- Simple, non-invasive tool to evaluate patients complaining of LUTS
- Gives an indication of Voiding patterns/Symptom severity
What can be considered a Moderate IPSS?
Moderate: 8-19
What is the approximate size of a 30 cc prostate?
Ping pong ball with 4cm diameter
What is a DRE?
- Assessment of Symmetry/Size/Surface Smoothness/Tenderness/MIDLINE GROOVE of Prostate assessed
- Pelvis and Rectum too
- Rectal tumours, Impaction too
Why is urinalysis done?
Identifies:
- Haematuria
- Glycosuria
- Proteinuria
- Pyuria
- Urinary Nitrites/Leucocytes
What does a dipstick test for?
- Microscopy and Culture for Microorganisms
What is NOT offered to men with LUTS?
- Cytoscopy with NO EVIDENCE of bladder issues
- Imagine of Upper UT with NO EVIDENCE of bladder issues
- Flow-rate measurement
- Post-void residual volume measurement
When would you offer men information/advice/time for a PSA test?
- If LUTS suggest Bladder Outlet Obstruction secondary to BPE
- Abnormal Prostate on DRE
- Prostate Cancer concern
If men have Storage LUTS (Urinary Incontinence usually), what can be offered as management?
- Pads/Collecting devices
If men have Storage LUTS but suggestive of an Overactive Bladder, what can be offered as management
- Supervised Bladder Training
- Advice for fluid intake
- Lifestyle advice
- Containment products
What are the main aims of treatment in BPH?
- Improving LUTS (Voiding/Storage)
- Improving QoL
- Prevent BPE/BPO-related complications
If the LUTS is not bothersome to the patient, what should we do?
Active Surveillance
- Reassurance
- Advice for lifestyle mods
- Offer review if symptoms change
If the LUTS is complicated and bothersome to the patient, what should we do?
Active Intervention
- Conservation Management
- Drug treatment/Surgery
- Offer baseline assessment (IPSS)
What Conservative management can we provide to those with an Overactive Bladder?
- Supervised Bladder Training
- Advice on fluid intake
- Lifestyle advice
- Containment products
What Conservative management can we provide to those with Stress Incontinence caused by Prostatectomy?
Supervised Pelvic Floor Muscle Training
What do we not offer for those with storage symptoms?
Penile clamps
What Conservative management can we provide to those with voiding symptoms?
- Intermittent Bladder Catheterisation before indwelling urethral/suprapubic catheterisation (If LUTS cannot be corrected by less invasive measures)
- Bladder training > Surgery
- Explain how Urethral Milking works for those with Post Micturition dribble
What Drug treatment can we offer men with Moderate-Severe LUTS?
Alpha Blocker
What Drug treatment can we offer men with LUTS and a Prostate 30+g or PSA 1.4+ ng/ml and high risk of progression?
5-Alpha Reductase Inhibitor
What Drug treatment can we offer to men with Bothersome moderate-severe LUTS and a prostate 30+g or PSA 1.4+ng/ml
Combination of Alpha Blocker and 5ARI
What does 5ARI drugs do to manage BPH?
- Decrease in Dihydrotestosterone synthesis
- Reduced androgenic drive of prostate
- Reduction in prostate volume = Improved outflow
What do Alpha blockers do to manage BPH?
- Block A1 receptors in prostate/urethra/bladder neck and detrusor
- Relaxes smooth muscle to improve urinary flow
Give Two examples of 5-ARIs
Finasteride and Dutasteride
When do we offer men Alpha Blockers for BPH?
- Moderate to Severe LUTS with no risk factors for progression
Give 3 reasons why giving Alpha Blockers is advantageous for men with LUTS?
- No effect on Prostate Volume/PSA
- No effect on serious BPH complications (Acute urinary retention)
- MTOPS study suggests no effect on disease progression over 4 years
What are the Risk Factors for the Progression of BPH?
- Age over 70
- Moderate-Severe Symptoms (IPSS > 7)
- PSA > 1.4 ng/ml
- Prostate Volume >30 cc
- Flow Rate <12 ml/sec
What is the Pathophysiology fo 5ARI?
- Testosterone binds to it alongside NADPH and 5AR
2. This will prevent conversion of Testosterone to DHT to slow disease progression
What is a main side effect of 5ARI?
Sexual function issues
What enzyme does Finasteride inhibit?
5AR Type II Isoenzyme
What enzyme does Dutasteride inhibit?
Dual inhibitor of 5AR Type I and Type II Isoenzyme
Which drugs reduce Prostatic Volume?
5ARI
What were the names of the two drugs involved in combination therapy for BPH?
Tamsulosin
Avodart
According to NICE, what drug is recommended for an Overactive Bladder?
Anticholinergic
According to NICE, what drug is best suited for those with Storage Symptoms dspite Alpha Blocker treatment?
Add an Anticholinergic on top
When do we review men who have taken Alpha Blockers for their LUTS/BPH?
4-6 weeks
THEN every 6-12 months
When do we review men who have taken 5ARI for their LUTS/BPH?
3-6 months
THEN every 6-12 months
When do we review men who have taken Anticholinergics for their LUTS/BPH?
4-6 weeks
THEN every 6-12 months
When would you recommend Specialist Assessment for LUTS/BPH?
- Bothersome LUTS and have not responded to Conservative/Drug Treatment
- LUTS complicated by UTI
- Retention
- Renal Impairment
- Urological Cancer
- Stress urinary incontinence
What does NICE recommend on managing Acute Urinary Retention?
- Catheterisation of Men with acute retention
2. Offer Alpha blocker to them before withdrawing the catheter
For Patients trying to manage their Voiding LUTS secondary to BPE, what should be offered as Surgery?
- Monopolar/Bipolar Transurethral Resection of Prostate (TURP)
- Monopolar Transurethral Vaporisation of Prostate (TUVP)
- Holmium Laser Enucleation of Prostate (HoLEP)
- Open prostatectomy (80+g Prostate)
For Patients trying to manage their Voiding LUTS secondary to BPE, what should NOT be offered as Surgery?
Minimally invasive treatments
- Transurethral Needle ablation (TUNA)
- Transurethral Microwave Thermotherapy (TUMT)
- High-intensity focused US (HIFU)
- Transurethral Ethanol Ablation of Prostate (TEAP)
- Laser Coagulation
When should surgery be offered to LUTS/BPE patients?
- When voiding symptoms are severe
2. Drug treatment/Conservative management have been unsuccessful/inappropriate
For individuals with Detrusor overactivity, what should be offered as surgical treatment?
- Cystoplasty: Also willing to self-catheterise
- Bladder Wall Injection with Botulinum: Also willing to self-catheterise
- Implanted sacral nerve stimulation
For individuals with Stress Urinary Incontinence, what should be offered as surgical treatment?
- Implantation of an artificial sphincter
2. Intramural injectables
