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RDS Test 3 > B8.040 Benign Prostatic Hyperplasia > Flashcards

B8.040 Benign Prostatic Hyperplasia Flashcards

1
Q

differential diagnosis of BPH

A 
infection
bladder tumor/stone
urethral stricture
bladder neck dysfunction
neurological issue
medication side effect
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2
Q

medications that can cause urinary symptoms

A

decongestants
antidepressants
antipsychotics

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3
Q

why do neuro issues cause urinary symptoms

A

lose descending inhibition from the brain

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4
Q

obstructive urinary symptoms

A 
weak stream
hesitancy
intermittency
incomplete emptying
dribbling
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5
Q

irritative urinary symptoms

A

urgency +/- incontinence
frequency
nocturia

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6
Q

what is BPH

A

increased number of epithelial and stromal cells in the prostate
-increased proliferation (early ) vs impaired apoptosis

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7
Q

cause of BPH

A
  1. androgen influence
    - T and DHT
    - 5a reductase type 1 and type 2
    - do not cause BPH, but are permissive in its development
  2. complex interplay between stroma and epithelium
    - growth factors, cytokines, inflammatory pathways, estrogens
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8
Q

anatomic/ histologic features of BPH

A

first develops in transition zone
contained within prostate capsule
size DOES NOT correlate with obstruction

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9
Q

impact of prostatic smooth muscle on BPH

A

40% of prostatic volume

  • contain alpha adrenergic receptors
  • important for treatment and for determining underlying cause if patients are on autonomic drugs
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10
Q

bladder response to BPH

A

smooth muscle hypertrophy> detrusor instability
increased collagen/ECM deposition over time > eventually decreases compliance
decreased contractility

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11
Q

diagnostic testing for evaluation of BPH

A 
UA
post void residual
DRE 
PSA?
bladder diary
*BMP not necessary*
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12
Q

components of a UA

A 
pH
glucose
bilirubin
urobilinogen
ketone
specific gravity
blood
leukocytes
nitrites
protein
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13
Q

value of DRE in BPH assessment

A

size estimate at best

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14
Q

what is a bladder diary

A

ins and outs over 24-48 hours

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15
Q

what is the AUA symptom score/ international prostate symptom score

A

standardized questionnaire that is validated and reproducible

  • 7 questions about LUTS
  • 1 question about quality of life impact
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16
Q

LUTS assessed on I-PSS

A 
incomplete emptying
frequency
intermittency
urgency
weak stream
straining
nocturia
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17
Q

what is uroflowmetry

A 
measures flow rate over time
should have a bell curve shape
-complete emptying
-no hesitancy
-not too long
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18
Q

obstructive pattern on uroflowmetry

A

flattened curve, prolonged time

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19
Q

epidemiology of BPH

A 
histo prevalence:
no men under 30
88% of men in their 80s
BUT not all men with histological hyperplasia have clinical symptoms 
clinically:
18% in 40s
56% in 70s
20
Q

summarize the venn diagram of BPH prevalence

A

histological BPH > LUTS/bother > BPE (enlargement) > BOO (obstruction)

21
Q

other causes of detrusor instability (not BPH)

A

detrusor aging effects
neurogenic disease
primary bladder disease

22
Q

3 treatment options for BPH

A

watchful waiting
medical
surgical

23
Q

medical treatment options

A 
alpha blocker
5a reductase inhibitors
PDE5 inhibitors
anticholinergics
beta-3 agonists
24
Q

mechanism of alpha blockers in BPH treatment

A

large portion of prostate is smooth muscle (40%)

a-1 inhibition leads to prostatic relaxation

25
Q

alpha blocker options

A

nonselective: affect vessels, so need to be titrated to avoid orthostatic hypotension
-doxazosin
-terazosin
-alfuzosin
a1A subtype selective: not as many systemic effects
-tamsulosin
-silodosin

26
Q

mechanism of action of 5a reductase inhibitors in BPH

A

block conversion of T to DHT

-DHT has higher affinity for androgen reception, thus is more likely to lead to increased transcription and translation

27
Q

outcome of 5a reductase inhibitors

A

reduces prostate volume by around 20%
-takes up to 6 months
more effective and studied in large glands (>40 g)
only medication to reduce future need for surgery

28
Q

5a reductase inhibitor options

A

finasteride (type 2)

dutasteride (type 1 and 2)

29
Q

mechanism of PDE5 inhibitors in BPH

A

prostate contains type 4, 5, 11 PDE
thought to act by NOS mediated smooth muscle relaxation
-increases NOS

30
Q

PDE5 inhibitor options

A

levitra 5 mg daily
2nd or 3rd line, expensive
very effective at lowering symptom scores and improving flow

31
Q

use of anticholinergics and B3 agonists in BPH

A

reduce bladder (irritative) symptoms
use with caution in patients with poor emptying
-may precipitate retention

32
Q

anticholinergic/ b agonist options

A 
anticholinergics:
oxybutynin
tolterodine
fesoterodine
trospium
darifenacin
solfenacin
beta-3 agonist:
mirabegron
ER formulation has fewer side effects
use with caution in patients with increased fall risk (ex: parkinson's, alz)
33
Q

PSA screening recommendations

A

shared decision making
men ages 55-70
1-2 year intervals

34
Q

abnormal uroflow

A

<10 cc/sec means there is a high probability of obstruction

35
Q

side effects of finasteride

A

sexual dysfunction
gynecomastia
breast tenderness
weight gain

36
Q

minimally invasive treatment options for BPH

A

rezum

urolift

37
Q

rezum

A 
water vapor (steam) therapy of adenoma
heat destroys adenoma
tissue resorbed, opening prostatic urethra
38
Q

urolift

A

small, permanent staple like implants

displace prostatic lobes and hold apart

39
Q

pros/cons of minimally invasive procedures

A 
pros:
-nonsurgical
-outpatient
-rapid return to activity
-improve both urinary symptoms and urinary flow rates
cons:
-long term efficacy data lacking
40
Q

TURP

A 
transurethral resection of prostate
historical gold standard
operative procedure
used for glands < 100 g
short hospital stay
41
Q

monopolar vs bipolar TURP

A

monopolar requires sterile water or glycine irrigation

  • sterile water can get into intravenous space and cause hyponatremia
  • glycine mimics GABA and can cause altered mental status
42
Q

types of laser ablation/ vaporization of prostate

A

holmium
thulium
greenlight

43
Q

describe laser ablation/ vaporization of prostate

A

saline irrigation
less blood loss, need for transfusion, shorter catheterization
can be done outpatient

44
Q

con of laser ablation/ vaporization of prostate

A

no tissue for pathology

45
Q

laser enucleation of prostate

A
  1. laser incision is made between prostatic capsule and adenoma
  2. tissue is resected in bloc, amputated, and pushed into bladder
  3. tissue is then morcellated mechanically and evacuated
46
Q

benefits of enucleation of the prostate

A

provides tissue for path
can be used with very large glands
largely supplanted open surgery
excellent outcomes overall

47
Q

simple prostatectomy

A

done for glands > 100g
potential for large blood loss
prolonged catheterization

RDS Test 3 (15 decks)

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