41. Benign Prostate Hyperplasia (BPH) Flashcards
what is the definition of BPH (benign prostate hyperplasia)
what are the 3 parts to the defintion
BPH is 1) benign enlargement of the prostate gland over 20cc/cm3?// 11g 2)causing obstruction leading to LUTS and on 3) uroflowometry w/ a q max (max urination) is less than 15ml/sec // elevated urinary sx score
which tissues comprise the prostate gland
which tissue is more likely to undergo hyperplasia
what are the 3 histological types of cells in the prostate
stromal and epithelial tissues
stromal tissues undergo hyperplasia 80% of the time
epithelial tissues can also undergo hyperplasia
histological cell types of prostate
- Glandular- 92% causing adenocarcinoma
- myoepithelial cells
- subepithelial intenrstitial cells
what is the difference between Hyperplasia and Hypertrophy
Hyperplasia= increas in cell number that occurs in cancers
Hypertrophy= increase in cell size that occurs in muscle growth
2 pathological mechanisms of obstruction in BPH causing LUTS
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60% d/2 Hyperplasia: cells grow in NUMBER caused by the increased level of dehydrotestosteroone catalyzed from testosterone by 5 alphareductase causing:
- Narrowing of prostatic urethra
- Elongation of prostatic urethra as enlarged PG raises trigone of UB
- Distortion of prostatic urethra from assymetrical enlarged PG tubules
- 40% d/2 SM constriction alpha 1 receptors stim of SM of the 1)prostate gland stroma, 2)periurethral sm and 3)bladder neck causing constrictions and obstruction & LUTS
Describe the Contemporary concept of Prostatic Growth
- roles of DHT
- role of 5alpha reductase
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- Prostate gland is androgen dependant: needs testosterone for growth and function
- when androgens target prostate it converts testosterone into Dihydrotestosterone by action of 5alphareductase
- DHT is 2.5x more biologically active than testosterone
- when DHT eventually binds to prostate androgen recepters the DHT androgen receptor complex forms
- complex enters cells and modulates 1)gene expresh 2) protein synthesis
- This modulation by the more bioactive DHTcomplex causes an increased response in Stomal and Epithelial tissues of prostate gland
- stromal and epithelial hyperplasia occurs and as theses are the 2 components of the prostate gland it is known as BPH
what is the epidemiology of BPH
which wre the 2 rf
WHAT age has the highest incidence rate
- risk increases w/ AGE: highest risk over 50 y/o
- Th/4: pts over 45 req mandatory PSA check in uro
- Race: whites people most affected
- blacks more at risk for prostate cancer so it’s fair
what are the sx of BPH
what are the 3 groups of this general sx
Lower Urinary Tract Symptoms
- Storage- related to bladder. irritative sx
- Voiding- act of ruination and urethral flow. obs sx
- Post voiding- after urination
list the 3 examples of Storage sx
syndrome comprises all 3 sx
- increased freq: over 8x/24hrs
- Urgency w/ or w/o uncontinence
- Nocturia
- OAB= all 3 above
list the 7 V O I D I N G sx
S H O W, U P, T
H O W’S, U P, T
- Hesitancy
- Straining
- Weak urinary stream
- Terminal dribbling
- Prolonged urinatino
- Urinary retention
- Overflow incontinence
list the 2 Postvoiding sx
- dribbling after urination
- feeling imcomplete voiding
what is the anatomic location of the prostate gland
below the urinary bladder
how are LUTS catagorised into mild moderate and severe
IPSS = international prostate sx score. max score is 35
7 questions 0-5
0-7 mild = surveilance & WW
8-19 mod = Conservative rx. surgery in some cases
20-35 is severe = Surgery is reccomended
NB= expression og sx status of BPH is 0-35 + QoL of 0-6
5 compications of BPH
- Urinary retention most common
- Rpx infection from retention
- Urolithiasis = stasis
- Acute/ chronic renal failure d/2 stasis from retention
- Hematuria = growth of prostate tissue is assoc with vascularisation
how are the complications of BPH classified in urology
which is the 1st alarming sx for bph
what is predisposition for stones and uti’s in bph
what are the 2 complications of compression of the ureter by the prostate
at the level of the Lower Urinary Tract
- URINARY RETENTION
- acute: 1st alarming sx for bph
- chronic: freq and painless. predisposition for mx stones / UTI
- => struvite combo
at the level of Upper Urinary Tract
- BILATERAL HYDRONEPHROSIS
- d/2 enlarged prostate compressing ureters
- predisposes to
- ACUTE/Chronic Renal Failure
- Ascending pyelonephritis
sx of acute KF
anuria
diagnostic steps for BPH
- history & IPSS
- Phys exam w/ DRE
- LAB: -bloods especially PSA -Urine analysis -Kidney func
- US: trans abdominal/ transrectal
What is the purpose od DRE in bph
what findings on DRE indicate abrnormal findings
- check suspicions for US.
- If suspicious transrectal US guided biopsy
- abnormal findings include
- hard prostate
- obliterated median sulcus
what is the purpose of US in BPH regarding the PG
what is the requirement of US for bph
what can US dg at both the Upper & Lower urinary tracts
full bladder required for exam?? not sure
- used to determine the size of the prostate- 20nm = normal
- used to determine type of prostatic growth=
- 1) subvesical or 2) endovesical
UUT level: dg urinary retention by residual urine under 30ml = normal
LUT level dg presence or abscence of stones
LAB inv for BPH
what is checked in the blood
what is checked in urine
which one d the 2 is useful for early detection of BPH
blood
- PSA= 0-4mg/dl is normal
- CBC & anemia
- Leukocytosis for infection
- renal func: creatinine etc
urine
Analysed for early detection
what are the 4 types of rx for BPH
- Watchful waiting for mild sx (IPSS0-7) and young pts every 6mo-year
-
Conservative rx: (IPSS:8-19)
- 1) alpha blockers with fast effect. Only symptomatic relaxation of sm in pg. periurethral tissue and bladder neck
- 2) 5alphareductase inhibitors
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Combined therapy for pts at risk of disease progression
- alpha blockers + 5 reductase inhibitors
-
pt’s at risk:
- PSA over 1.5 nanograms
- Prostate over 40-cc/g.
- Q max below 10%
- SURGICAL rx.
- sever IPSS (20-35)
- Below 80cc = gold standard TURP
- Above 80cc is open prostatectomy
- C.I. for other methods or poor ECOG =
- balloon dilation
- stent
Side effects of alpha blockers
Hypotension so people with low BP are contraindicated for this drug
Retrograde ejaculation in young patients and can afffect fertility
- also occurs in R.P LN dissection of NGC TT
Side effects of 5 alphareductase inhibitors
Reduced libido and ED
Constipation
Dizziness
Malignancy
when is PSA mandatory
every pt over 45 espicially if tey present w/ LUTS
Combined therapy for pts at risk of disease progression
alpha blockers + 5 reductase inhibitors are for which pts?
pt’s at risk:
PSA over 1.5 nanograms
Prostate over 40cc/g.
Q max below 10%
pts indicated for surgery
sever IPSS (20-35)
Below 80cc = gold standard TURP
Above 80cc is open prostatectomy
C.I. for other methods or poor ECOG =
