B8.040 Benign Prostatic Hyperplasia

Question 1

differential diagnosis of BPH

Answer 1

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

Question 2

medications that can cause urinary symptoms

Answer 2

decongestants
antidepressants
antipsychotics

Question 3

why do neuro issues cause urinary symptoms

Answer 3

lose descending inhibition from the brain

Question 4

obstructive urinary symptoms

Answer 4

weak stream
hesitancy
intermittency
incomplete emptying
dribbling

Question 5

irritative urinary symptoms

Answer 5

urgency +/- incontinence
frequency
nocturia

Question 6

what is BPH

Answer 6

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

Question 7

cause of BPH

Answer 7

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

Question 8

anatomic/ histologic features of BPH

Answer 8

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

Question 9

impact of prostatic smooth muscle on BPH

Answer 9

40% of prostatic volume

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

Question 10

bladder response to BPH

Answer 10

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

Question 11

diagnostic testing for evaluation of BPH

Answer 11

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

Question 12

components of a UA

Answer 12

pH
glucose
bilirubin
urobilinogen
ketone
specific gravity
blood
leukocytes
nitrites
protein

Question 13

value of DRE in BPH assessment

Answer 13

size estimate at best

Question 14

what is a bladder diary

Answer 14

ins and outs over 24-48 hours

Question 15

what is the AUA symptom score/ international prostate symptom score

Answer 15

standardized questionnaire that is validated and reproducible

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

Question 16

LUTS assessed on I-PSS

Answer 16

incomplete emptying
frequency
intermittency
urgency
weak stream
straining
nocturia

Question 17

what is uroflowmetry

Answer 17

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

Question 18

obstructive pattern on uroflowmetry

Answer 18

flattened curve, prolonged time

Question 19

epidemiology of BPH

Answer 19

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

Question 20

summarize the venn diagram of BPH prevalence

Answer 20

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

Question 21

other causes of detrusor instability (not BPH)

Answer 21

detrusor aging effects
neurogenic disease
primary bladder disease

Question 22

3 treatment options for BPH

Answer 22

watchful waiting
medical
surgical

Question 23

medical treatment options

Answer 23

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

Question 24

mechanism of alpha blockers in BPH treatment

Answer 24

large portion of prostate is smooth muscle (40%)

a-1 inhibition leads to prostatic relaxation

Question 25

alpha blocker options

Answer 25

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

Question 26

mechanism of action of 5a reductase inhibitors in BPH

Answer 26

block conversion of T to DHT | -DHT has higher affinity for androgen reception, thus is more likely to lead to increased transcription and translation

Question 27

outcome of 5a reductase inhibitors

Answer 27

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

Question 28

5a reductase inhibitor options

Answer 28

finasteride (type 2) | dutasteride (type 1 and 2)

Question 29

mechanism of PDE5 inhibitors in BPH

Answer 29

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

Question 30

PDE5 inhibitor options

Answer 30

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

Question 31

use of anticholinergics and B3 agonists in BPH

Answer 31

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

Question 32

anticholinergic/ b agonist options

Answer 32

``` 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) ```

Question 33

PSA screening recommendations

Answer 33

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

Question 34

abnormal uroflow

Answer 34

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

Question 35

side effects of finasteride

Answer 35

sexual dysfunction gynecomastia breast tenderness weight gain

Question 36

minimally invasive treatment options for BPH

Answer 36

rezum | urolift

Question 37

rezum

Answer 37

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

Question 38

urolift

Answer 38

small, permanent staple like implants | displace prostatic lobes and hold apart

Question 39

pros/cons of minimally invasive procedures

Answer 39

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

Question 40

TURP

Answer 40

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

Question 41

monopolar vs bipolar TURP

Answer 41

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

Question 42

types of laser ablation/ vaporization of prostate

Answer 42

holmium thulium greenlight

Question 43

describe laser ablation/ vaporization of prostate

Answer 43

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

Question 44

con of laser ablation/ vaporization of prostate

Answer 44

no tissue for pathology

Question 45

laser enucleation of prostate

Answer 45

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

Question 46

benefits of enucleation of the prostate

Answer 46

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

Question 47

simple prostatectomy

Answer 47

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