A/20. Symptoms and differential diagnosis of BPH A/21. Conservative and surgical treatment of BPH Flashcards
Benign prostatic hyperplasia (BPH) define
benign glandular and stromal
hyperplasia of the transitional zone of the prostate
Epidemiology of Benign prostatic hyperplasia (BPH) age group
- 50% of men >50 yrs
- 80% of men >80 yrs
Benign prostatic hyperplasia (BPH) etiologies
- Hormonal factors
*Androgens: Dihydrotestosterone (DHT) potent prostatic growth factor
*Estrogens (mainly estradiol) are potent stimulators of prostatic hyperplasia)
*Androgen-estrogen imbalance - Stem cell proliferation and longevity: abnormal proliferation and longer prostatic stem cell life-span
- Genetic susceptibility
how can Dihydrotestosterone (DHT) cause BPH
is a potent prostatic growth factor.
- Gene amplification of androgen receptors (present in the glandular epithelial cells and stromal cells) -> increased androgen receptor sensitivity to androgens -> prostatic hyperplasia
Androgen-estrogen imbalance how can it lead to BPH
as men age, testosterone levels decline,
but estrogen levels remain the same, which results in a higher estrogen/testosterone ratio
Estrogens are potent stimulators of prostatic hyperplasia
Genetic susceptibility - what gene involved in the development of BPH
- growth factor genes,
- androgen-regulator genes
- apoptosis genes
- and androgen-regulated genes.
which zones or lobes of prostate are involved in development of BPH
- middle transition zone/the lateral and middle prostatic lobes (periurethral lobes)
when is the outer peripheral zone involved? in what?
The outer peripheral zone is involved in development of prostate cancer
pathophysiology of BPH development?
A combination of hormonal factors, stem cell proliferation and genetic susceptibility
–> glandular and stromal hyperplasia in the transition zone
–> formation of smooth elastic firm hyperplastic nodule
–> slit-like prostatic urethral compression
–> BOO
–> BPH obstructive symps
what does Bladder outlet obstruction leads to?
-predisposition to what
detusor hyperactivity (involuntary detrusor’s contraction during bladder filling) –> irritatove symps of BPH
bladder wall weakens –> incomplete voiding –> urinary stasis –> predisposition to:
1. UTIs
2.acute/chronic urinary retention
3. formation of bladder stones
4. increased intra cystic pressure while voiding
which all will lead to detursor muscle hypertrophy resulting in:
=> bladder trabeculation ( walls of the bladder thicken, making them harder to contract)
=>pseudo-diverticula formation
BPH clinical findings?
- Irritative symptoms
- Obstructive symptoms
what are the irritative symps of BPH?
urinary frequency
urinary urgency and urge incontinence
nocturia
occasionally dysuria
what are the obstructive symps of BPH?
hesitancy=Difficulty starting or maintaining a urine stream
straining to urinate= need strain or push (Valsalva maneuver) to initiate and maintain urination in order to more fully empty the bladder
poor and/or intermittent stream (not continuous)
prolonged terminal dribbling
acute urinary retention
how do you diagnose BPH?
- History
- Voiding diary
- IPSS=International Prostate Symptom Score
- PSA levels
- DRE
- Transrectal US
- Uroflowmetry
- Cystoscopy, urodynamic investigation
what is IPSS?
International Prostate Symptom Score (IPSS)
-it is a questionnaire of 8 items which categorizes the pts. into asymptomatic, mildly symptomatic, moderately symptomatic or severely symptomatic.
what are the 8 points of IPSS?
- Feeling of incomplete emptying?
- Frequency? (<2 hrs in between)
- Intermittency (staccato)?
- Weak stream?
- Straining?
- Nocturia?
- Quality of life?
- How would you feel if you were to spend the rest of your life w/ your condition?
what do you find on DRE looking for BPH?
symmetrically enlarged
smooth
firm
nontender
rubbery or elastic texture
BPH differential diagnosis
prostate cancer
bladder cancer
atonic bladder
urethral structure
sphincter sclerosis
what does BPH treatment includes?
Behavioral and dietary alterations
Pharmacological management
Surgical management
what are the Behavioral and dietary alterations in BPH treatment?
- Reduction of fluid intake
- Avoid/moderate alcohol and caffeine consumption
- Use of relaxed and double-voiding techniques (urinating as much as possible, relaxing for a few moments, and then urinating again)
- Bladder training
- Review of medication and optimization of the time of administration or substituting drugs
(especially for diuretics and treatment of constipation)
what is the Pharmacological management of BPH?
- Plant extracts
- alpha-antagonists (tamsulosin, tera, dosa)
- Phosphodiesterase-5 inhibitors (tadalafil)
- Combined therapies (available for LUTS) =
a-blocker + 5-a reductase inhibitor
OR
a-blocker+ muscurinic blocker
explain plant extracts treatment in the Pharmacological management of BPH…
anticongestive
anti-estrogen
anti-inflammatory
only few side effects so it is recommended in mild symptoms
explain alpha-antagonists treatment in the Pharmacological management of BPH..
Relaxes internal sphincter; increases flow and decreases residual urine
drugs:
Silodosin
tamsulosin
alfuzosin
doxazosin
terazosin
how does the alpha-antagonists treat BPH?
side effects?
they relax the internal sphincter –> increase flow and decrease the residual urine.
- most have long-acting effect
- side effects:
1. hypotony
2. retrograde ejaculation (occurs when semen enters the bladder instead of emerging through the penis during orgasm)
3. decrease libido
4. ED= erectile dysfunction
explain Phosphodiesterase-5 inhibitors (tadalafil) treatment in the Pharmacological management of BPH..
act through:
- IC.cGMP (arterial sm relax, increased arterial inflow; erection)
- NO
=> increase blood perfusion and oxygenation
explain Combined therapies treatment in the Pharmacological management of BPH
alpha-blocker + 5alpha-reductase inhibitors
OR
alpha-blocker + muscarinic antagonists
what kind of surgical treatment are available for BPH?
Transurethral resection of prostate (TURP)
Laser treatment
Hyperthermia
Thermotherapy
High intensity focused US (HIFU)
Transurethral microwave therapy
Transurethral needle ablation of prostate (TUNA)
Prostating stents
