Benign Disease Of The Prostate And Urinary Tract Obstruction Flashcards
What is benign prostatic hyperplasia characterised by?
fibromuscular and glandular hyperplasia
What area is affected in BPH?
Transition zone
What happens in BPH?
Disordered regulation of dihydrotestosterone
What is the prevalence of BPH?
50% of men at 60 years
90% of men at 85 years
What can occur in BPH?
50% of men with BPH have moderate to severe LUTS
What can BPH lead to?
Progressive condition resulting in Benign Prostatic Obstruction (BPO) or Bladder Outflow Obstruction (BOO)
What is the scoring system for LUTS?
IPSS
What are factors considered in voiding assessment?
Hesitancy
Poor stream
Terminal dribbling
Incomplete emptying
What are the factors assessed in storage of LUTS?
Frequency
Nocturia
Urgency +/- urge incontinence
What is the scoring of IPSS?
Total score (out of 35) :
Mild : 0-7
Moderate : 8-19
Severe : ≥ 20
What is seen in an examination of LUTS?
Abdomen
? palpable bladder
Penis
? external urethral meatal stricture
? phimosis
Digital rectal examination (DRE)
assess prostate size
? suspicious nodules or firmness
Urinalysis
? blood
? signs of UTI
What investigation are done for LUTS?
MSSU
Flow rate study
Post-void bladder residual USS
Bloods :
PSA
urea and creatinine (if chronic retention)
Renal tract USS if renal failure or bladder stone suspected
Flexible cystoscopy if haematuria
Urodynamic studies in selected cases
TRUS-guided prostate biopsy if PSA raised or abnormal DRE
What are the two typed of BPO?
Uncomplicated
Complicated
What is the treatment of BPO?
Watchful waiting
Medical therapy
-5 alpha reductase inhibitors (Finasteride or -Dutasteride)
-Alpha blockers
-Combination
Surgical intervention
-TURP (prostate size <100cc)
-Open retropubic or transvesical prostatectomy (prostate size >100cc)
-Endoscopic ablative procedures
What is the main treatment of LUTS due to BPO?
Alpha blockers
How do alpha blockers work?
Smooth muscle of bladder neck (i.e. intrinsic urethral sphincter) and prostate innervated by sympathetic alpha-adrenergic nerves (mostly alpha-1a subtype)
Alpha blockers cause smooth muscle relaxation and antagonise the ‘dynamic’ element to prostatic obstruction
What are the types of alpha blockers?
- non-selective (i.e. alpha 1 and 2) : phenoxybenzamine
- selective short acting : prazosin, indoramin
- selective long acting : alfuzosin, doxazosin, terazosin
- highly selective (i.e. alpha-1a) : tamsulosin
What do 5a-reductase do?
5a-reductase converts testosterone to dihydrotestosterone.
What two drugs are available for 5a-reductase inhibitors?
- Finasteride (5AR Type II inhibitor)
- Dutasteride (5AR Type I and II inhibitor)
What is the role of 5ARIs?
- reduces prostate size and reduces risks of progression of BPE
(but only if >25cc prostate)- also reduces LUTS (but not as effective as alpha blockers)
- combination therapy of 5ARIs + alpha blockers most effective
in reducing risk of progression of BPE - can also reduce prostatic vascularity and hence reduces
haematuria due to prostatic bleeding - potential role in prostate cancer prevention
What is TURP?
Transurethral resection of prostate
What is TURP?
gold standard for surgical management of BPE causing BOO (except for prostate size >100cc)
What can TURP be done using?
Can be done using glycine (monopolar TURP) or saline (bipolar TURP)
What can TURP help in?
Very effective in relieving symptoms and improves urodynamic parameters (90% efficacy at 1 year)
What are complications of TURP?
- bleeding, infection, retrograde ejaculation, stress urinary
incontinence, prostatic regrowth causing recurrent haematuria
or BOO
What prostate size is too large for TURP?
> 100 cc