B8.040 Benign Prostatic Hyperplasia Flashcards
differential diagnosis of BPH
infection bladder tumor/stone urethral stricture bladder neck dysfunction neurological issue medication side effect
medications that can cause urinary symptoms
decongestants
antidepressants
antipsychotics
why do neuro issues cause urinary symptoms
lose descending inhibition from the brain
obstructive urinary symptoms
weak stream hesitancy intermittency incomplete emptying dribbling
irritative urinary symptoms
urgency +/- incontinence
frequency
nocturia
what is BPH
increased number of epithelial and stromal cells in the prostate
-increased proliferation (early ) vs impaired apoptosis
cause of BPH
- androgen influence
- T and DHT
- 5a reductase type 1 and type 2
- do not cause BPH, but are permissive in its development - complex interplay between stroma and epithelium
- growth factors, cytokines, inflammatory pathways, estrogens
anatomic/ histologic features of BPH
first develops in transition zone
contained within prostate capsule
size DOES NOT correlate with obstruction
impact of prostatic smooth muscle on BPH
40% of prostatic volume
- contain alpha adrenergic receptors
- important for treatment and for determining underlying cause if patients are on autonomic drugs
bladder response to BPH
smooth muscle hypertrophy> detrusor instability
increased collagen/ECM deposition over time > eventually decreases compliance
decreased contractility
diagnostic testing for evaluation of BPH
UA post void residual DRE PSA? bladder diary *BMP not necessary*
components of a UA
pH glucose bilirubin urobilinogen ketone specific gravity blood leukocytes nitrites protein
value of DRE in BPH assessment
size estimate at best
what is a bladder diary
ins and outs over 24-48 hours
what is the AUA symptom score/ international prostate symptom score
standardized questionnaire that is validated and reproducible
- 7 questions about LUTS
- 1 question about quality of life impact
LUTS assessed on I-PSS
incomplete emptying frequency intermittency urgency weak stream straining nocturia
what is uroflowmetry
measures flow rate over time should have a bell curve shape -complete emptying -no hesitancy -not too long
obstructive pattern on uroflowmetry
flattened curve, prolonged time
epidemiology of BPH
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
summarize the venn diagram of BPH prevalence
histological BPH > LUTS/bother > BPE (enlargement) > BOO (obstruction)
other causes of detrusor instability (not BPH)
detrusor aging effects
neurogenic disease
primary bladder disease
3 treatment options for BPH
watchful waiting
medical
surgical
medical treatment options
alpha blocker 5a reductase inhibitors PDE5 inhibitors anticholinergics beta-3 agonists
mechanism of alpha blockers in BPH treatment
large portion of prostate is smooth muscle (40%)
a-1 inhibition leads to prostatic relaxation
alpha blocker options
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
mechanism of action of 5a reductase inhibitors in BPH
block conversion of T to DHT
-DHT has higher affinity for androgen reception, thus is more likely to lead to increased transcription and translation
outcome of 5a reductase inhibitors
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
5a reductase inhibitor options
finasteride (type 2)
dutasteride (type 1 and 2)
mechanism of PDE5 inhibitors in BPH
prostate contains type 4, 5, 11 PDE
thought to act by NOS mediated smooth muscle relaxation
-increases NOS
PDE5 inhibitor options
levitra 5 mg daily
2nd or 3rd line, expensive
very effective at lowering symptom scores and improving flow
use of anticholinergics and B3 agonists in BPH
reduce bladder (irritative) symptoms
use with caution in patients with poor emptying
-may precipitate retention
anticholinergic/ b agonist options
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)
PSA screening recommendations
shared decision making
men ages 55-70
1-2 year intervals
abnormal uroflow
<10 cc/sec means there is a high probability of obstruction
side effects of finasteride
sexual dysfunction
gynecomastia
breast tenderness
weight gain
minimally invasive treatment options for BPH
rezum
urolift
rezum
water vapor (steam) therapy of adenoma heat destroys adenoma tissue resorbed, opening prostatic urethra
urolift
small, permanent staple like implants
displace prostatic lobes and hold apart
pros/cons of minimally invasive procedures
pros: -nonsurgical -outpatient -rapid return to activity -improve both urinary symptoms and urinary flow rates cons: -long term efficacy data lacking
TURP
transurethral resection of prostate historical gold standard operative procedure used for glands < 100 g short hospital stay
monopolar vs bipolar TURP
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
types of laser ablation/ vaporization of prostate
holmium
thulium
greenlight
describe laser ablation/ vaporization of prostate
saline irrigation
less blood loss, need for transfusion, shorter catheterization
can be done outpatient
con of laser ablation/ vaporization of prostate
no tissue for pathology
laser enucleation of prostate
- laser incision is made between prostatic capsule and adenoma
- tissue is resected in bloc, amputated, and pushed into bladder
- tissue is then morcellated mechanically and evacuated
benefits of enucleation of the prostate
provides tissue for path
can be used with very large glands
largely supplanted open surgery
excellent outcomes overall
simple prostatectomy
done for glands > 100g
potential for large blood loss
prolonged catheterization
