240: Benign Prostatic Hyperplasia Flashcards
Which medications are proven to decrease prostate volume by ~20%?
Finasteride, dutasteride
(5-alpha-reductase inhibitors)
Also decreases PSA by 50%
But takes up to 6 months
List the 3 stages of BPH
What size and symptoms occur at each stage?
- Stage 1 = Histologic
- Stage 2 = Clinical (can discover on exam)
- Stage 3 = Symptomatic (pt has sx)
LUTS= lower urinary track symptoms
DRE= digital rectal exam
Which structures make up the 1st, 2nd, and 3rd anatomic/physiologic zones of the lower urinary tract?
Which receptors predominate in each zone?
- Zone 1
- Bladder (above the trigone)
- M3 (pelvic nerve), Beta-3 (hypogastic nerve)
- Zone 2
- Trigone to prostate
- Bladder neck, prostate, prostatic urethra
- Alpha-1 (pudendal nerve)
- Zone 3
- Membranous urethra
- Nicotinic ACh receptors (pudendal nerve)
When would surgical managment be preferred over medical for BPH?
- High AUR score (lots of symptoms)
- Bladder caliculi
- Large bladder diverticulum w/narrow neck + stasis
- Recurrent UTI
- Recurrent gross hematuria
- Overflow incontinence (bilateral hydronephrosis, azotemia)
- Lower urinary tract sx refractory to medical mangement
What is the half life of PSA?
2-3 days
What form of sexual dysfunction is associated with tamsulosin?
Retrograde ejaculation
Tamuslosin = Selective alpha-1A blocker, relaxes bladder neck
Semen can get into the bladder during ejaculation
Usually it is just peed out, no complaints
I guess only a problem if trying to conceive?
List the behavioral modifications that might be useful for mildy symptomatic pts with BPH (5)
- Double voiding
- Timed voiding (based on diary)
- Avoid caffein, EtOH, diruetics
- Night time fluid restriction
- Exercise
What ophthalmologic problem is associated with alpha-blockers?
Intra-operative floppy iris syndrome
Not a contra-indication, but ophthalmologist needs to know before catarct surgery
Higher rates of iris trauma, posterior capsule rupture during cataract surgery
What are the standard components of a BPH workup? (6)
- History
- Focused physical exam
- Digital rectal exam
- Urinalysis
- Creatinine
- PSA (in select pts)
DO NOT need urodynamics in most people
Which type of enzyme is PSA?
What is its function?
Serine protease
Liquifies semen
What is the major advantage of laser prostatectomy over conventional TURP?
Less bleeding
-> better hemostasis in an anticoagulated pt
Which herbal treatments work to treat BPH?
NONE of them
For which patients would combined pharmacologic therapy for BPH be most helpful?
(alpha-blocker + 5-alpha reductase inhibitor)
Moderate-severe sx
Prostate volume >40mL
Higher PSA
Advanced age
Which two types of drugs will work best for irratiative symptoms of BPH?
What needs to be monitored when patients take these medications?
M2/M3 blocker or beta-3 agonist
Goal is to prevent detrusor contraction or promote relaxation
Monitor post-void residual volume to avoid urinary retention
What does phosphodiesterase 5 do?
Breaks cyclic-GMP into GMP
Block this process with PDE-5 inhibitors→ promote vasodilation
Which phosphodiesterase enzymes are located in the prostae? (3)
4
5
11
PDE-5 inhibitors can help with ED and BPH
Which cells of the prostate produce PSA?
Adlumina/secretory cells
Which zone expand in BPH?
Transitional zone
On either side of the urethra
Which drug class would be best to treat a patient with BPH and erectile dysfunction?
PDE-5 inhibitors
(Sildinafil)
Age increases risk of both ED and BPH
Which embryonic structure is the prostate derived from?
Pelvic part of the UG sinus
How does chronic BPH affect the bladder?
Hypertrophy of the detrusor muscles.
Bladder has to generate lots of force to push urine out through enlarged prostate
Which enzyme converts testosterone to DHT?
5 alpha reductase
Which kind of cell is primarily responsible for the production of 5 alpha reductase (Type 2) in the prostate?
Stromal cells
What percent of men between the ages of 60-69 are affected by symptoms of BPH?
70%
How does exercise improve BPH-related lower urinary tract symptoms?
- decreased sympathetic NS activity
- improved sleep quality
- decreased systemic inflammation
What a-adrenergic receptor subtype is linked to smoth muscle contraction in the prostate?
Alpha 1a
What is an absolute indication for surgical management of BPH?
Recurrent episodes of gross hematuria with clot retention
