Benign Prostatic Hyperplasia Flashcards
What is benign prostatic hyperplasia?
A benign enlargement of the prostate gland
What McNeal prostatic zone of the prostate is most commonly affected by BPH?
Transitional zone
Which two prostatic lobes tend to be affected by benign prostatic hyperplasia?
Median lobe
Lateral lobe
What is the pathophysiological cause of benign prostatic hyperplasia?
Androgen dihydrotestosterone
Where is the prostate gland located?
It is a gland located between the bladder and the penis
Where is the prostate gland located in relation to the rectum?
Anterior
What urinary structure runs through the centre of the prostate gland?
Urethra - connecting the bladder to the penis
What is the function of the prostate?
It secretes proteolytic enzymes into the semen, which act to break down clotting factors in the ejaculate
This allows the semen to remain in a fluid state, moving through the female reproductive tract for potential fertilisation
How is the prostate histologically classified?
McNeal prostatic zones
What are the four McNeal prostatic zones?
Transition Zone
Centre Zone
Peripheral Zone
Anterior Fibromuscular Zone
What scoring system is used to classify benign prostatic hyperplasia?
International prostate symptom score (IPSS)
What is the international prostate symptom score (IPSS)?
This involves patients answering questions relating to the different symptoms they might be experiencing and their overall quality of life
What IPSS score defines mild benign prostatic hyperplasia?
0-7
What IPSS score defines moderate benign prostatic hyperplasia?
8-19
What IPSS score defines severe benign prostatic hyperplasia?
> 20
What six risk factors are associated with benign prostatic hyperplasia?
Older Age > 60 Years Old
Black Ethnicity
Family History
Obesity
Diabetes Mellitus
Cardiovascular Disease
What are the six clinical features of benign prostatic hyperplasia?
Polyuria
Nocturia
Dysuria
Urinary Incontinence
Urinary Urgency
Urinary Tract Infections
What is polyuria?
It is defined as an increased urine output > 3L/day
What is nocturia?
It is defined as waking up at night on more than one occasion to micturate
What is dysuria?
It is defined as painful or difficulty in urinating
What are the three clinical features of bladder outlet obstruction - a common complication of benign prostatic hyperplasia?
Urinary Hesitancy
Intermittent Flow
Incomplete Bladder Emptying
What is urinary hesitancy?
It is defined as a difficulty in starting urination
What is intermittent flow?
It is defined as a urine stream that starts and stops, with dribbling occurring at the end of urination
What are the five investigations used to diagnose benign prostatic hyperplasia?
Rectum Examination
Urine Dipstick Test
Post-Void Bladder Residual Test
Urinary Flow Test
Blood Tests
What are the three features of prostate cancer in a rectal exam?
Enlarged
Smooth
Palpable midline sulcus
How is a urine dipstick test used to diagnose benign prostatic hyperplasia?
It is used to rule out an urinary tract infection
What is a post-void residual urine test?
It measures the amount of urine left in the bladder after urination
The test can be done using an ultrasound or by inserting a catheter into the bladder.
What post-void residual urine test result indicates benign prostatic hyperplasia?
Positive
What is a urinary flow test?
It involves the patient urinating into a receptacle attached to a machine that measures the strength and amount of urine flow
What three urinary flow test results indicate benign prostatic hyperplasia?
Qmax < 10ml/s
Vv < 150mL
Urine Flow Chart = Peaks & Troughs
What is Qmax in a urinary flow test?
The maximum urinary flow rate
What is Vv in a urinary flow test?
The voided volume
What three blood test results indicate benign prostatic hyperplasia?
Increased Prostate Specific Antigen (PSA) Levels
Increased Urea Levels
Increased Creatinine Levels
What is PSA?
A substance produced in the prostate
When is conservative management used to treat benign prostatic hyperplasia?
In mild disease, in which individuals have not developed any significant complications
What is the conservative management option of benign prostatic hyperplasia?
Active monitoring
What are the two pharmacological management options of benign prostatic hyperplasia?
Alpha Blockers
5-Alpha Reductase Inhibitors
When are alpha-1 antagonists to manage benign prostatic hyperplasia?
It is the first line pharmacological management option - recommended when there are moderate to severe voiding clincial features indicated by an IPSS > 8
Name four alpha-1 antagonists used to manage benign prostatic hyperplasia
‘sin’
Tamsulosin
Alfuzosin
Doxazosin
Prazosin
What is the first line alpha-1 antagonist used to treat benign prostatic hyperplasia? Why?
Tamsulosin
It has a high selectivity to the prostate
What is the mechanism of action of alpha-1 antagonists?
They work by relaxing the smooth muscles of the bladder neck (intrinsic urethral sphincter) and muscle fibres in the prostate, which are innervated by the sympathetic alpha-one adrenergic nerves
This therefore makes urination easier
What are five side effects of alpha-1 antagonists?
Retrograde ejaculation
Dizziness
Postural hypotension
Dry mouth
Depression
What is a the most common side effect of alpha-1 antagonists?
Retrograde ejaculation
What is retrograde ejaculation?
It is when the semen enter back into the urinary bladder instead of out the penis tip
When are 5-alpha reductase inhibitors recommended to manage benign prostatic hyperplasia?
It is the second line pharmacological management option
What are the two disadvantages of using 5-alpha reductase inhibitors to treat benign prostatic hyperplasia instead of alpha blockers?
They can take up to six months to work
They are less effective in relieving symptoms
Name two alpha-5 reductase inhibitors used to manage benign prostatic hyperplasia
Finasteride
Dutasteride
What is the mechanism of action of 5-alpha reductase inhibitors?
5-alpha reductase is an enzyme involved in the conversion of testosterone to dihydrotestosterone, which is a hormone that promotes prostate growth
5-alpha reductase inhibitors inhibit this enzyme
What are four side effects of 5-alpha reductase inhibitors?
Erectile dysfunction
Reduced libido
Ejaculation problems
Gynaecomastia
What is the most common side effect of 5-alpha reductase inhibitors?
Erectile dysfunction
When is combination therapy of alpha blockers and 5-alpha reductase inhibitors recommended?
When individuals have moderate-to-severe voiding symptoms and prostatic enlargement
In which three circumstances is surgical treatment of benign prostatic hyperplasia considered?
If the patient suffers from moderate to severe symptoms
If pharmacological management hasn’t relieved the patient’s symptoms
If complication development occurs
What is the surgical management option used to treat benign prostatic hyperplasia?
Trans-urethral resection of the prostate (TURP)
What is TURP?
It involves removal of all but the outer aspect of the prostate
What are the four complications of TURP?
TURP
Turp syndrome
Urethral stricture/urinary tract infection
Retrograde ejaculation
Perforation of the prostate
What is TURP syndrome?
It is a condition in which there is venous destruction and absorption of the irrigation fluid (glycine) used during surgery
What are the seven risk factors of TURP syndrome?
Surgical time > 1 hr
Height of bag > 70cm
Resected > 60g
Large blood loss
Perforation
Large amount of fluid used
Poorly controlled congestive heart failure
What are the two blood test results of TURP syndrome?
Hyponatraemia
Hyperammonia
How do we treat patients who require surgery management of benign prostatic hyperplasia, however are deemed unfit?
Catheterisation
What are the five complications of benign prostatic hyperplasia?
Acute Urinary Retention
Chronic Urinary Retention
Acute Kidney Injury
Recurrent Urinary Tract Infections
Renal Calculi
