Benign Prostatic Hyperplasia Flashcards
Benign prostatic hyperplasia (BPH) is characterised by hyperplasia resulting in … … tract symptoms
Benign prostatic hyperplasia (BPH) is characterised by hyperplasia resulting in lower urinary tract symptoms (LUTS).
In BPH, prostatic hyperplasia (increased cell … leading to …) leads to urinary frequency, incomplete emptying, dribbling, hesitancy and nocturia. It may also be complicated by acute or chronic urinary ….
In BPH, prostatic hyperplasia (increased cell proliferation leading to enlargement) leads to urinary frequency, incomplete emptying, dribbling, hesitancy and nocturia. It may also be complicated by acute or chronic urinary retention.
BPE vs BPH?
You may come across the term benign prostatic enlargement (BPE). This refers to a clinical finding on digital rectal examination (DRE), BPH refers to a histological diagnosis.
BPH is common with incidence increasing with … ….
BPH is common with incidence increasing with advancing age.
What age do patients usually get BPH?
Whilst rare before the age of 40, it affects 30-40% of men older than 50. It is seen in around 90% of men aged 90. Men of African origin are more commonly affected.
Aetiology of BPH:
The aetiology of BPH is poorly understood.
BPH is common with increasing age. It is a hormone-dependent process involving testosterone and dihydrotestosterone production. A failure of normal apoptosis and abnormal epithelial and stromal proliferation have been implicated.
This proliferation occurs primarily in the transition zone of the prostate, this leads to restriction of the prostatic urethra and urinary flow.
Clinical features of BPH: (7)
Urinary frequency Nocturia Incomplete emptying Decreased urinary flow Dribbling Hesitancy Retention (acute or chronic)
Urinary frequency Nocturia Incomplete emptying Decreased urinary flow Dribbling Hesitancy Retention (acute or chronic)
All symptoms of what?
BPH
What is the name for the score that categorises the impact of prostate symptoms?
The International Prostate Symptom Score is a questionnaire that categorises the impact of prostate symptoms. (IPSS)
What are the IPSS categories?
It consists of seven questions about symptoms, each of which can be rated 0-5 depending on the frequency with which the symptoms are experienced. The scores of the seven symptomatic questions can be categorised as mild, moderate or severe.
A final (eighth) question asks about quality of life based upon the impact of the disease on a scale of 0-6.
What exam is vital in assessing the prostate?
Digital rectal examination
This is a key component of the examination and allows for assessment of the rough size of the prostate.
Irregular enlargement should raise concerns and further investigation for cancer. Evidence of reduced anal tone may be indicative of neurogenic causes of LUTS.
Urinary investigations in suspected BPH
Dip & MSU: in patients with LUTS, infection must be considered. This can be evaluated with a urine dipstick and MSU.
Post-void residual: bladder USS can be used to quantify residual volume (post-void refers to scanning after the patient has passed urine).
Bloods for suspected BPH (3)
FBC
UEs
LFTs (ALP may be elevated in prostatic cancer with bony metastasis)
Prostate-specific antigen (PSA) helps to do what?
Helps stratify the risk of prostate cancer. PSA is by no means a perfect test and may be elevated in the absence of malignancy.
Vigorous exercise and ejaculation should be avoided for 48hrs prior to the test. PSA may be elevated in (or following) urinary or prostatic infections or in the 6 weeks following a prostatic biopsy.
Imaging for suspected BPH
USS: this can be abdominal or transrectal. It can evaluate the size of the prostate. Also used in patients with urinary retention to evaluate for hydronephrosis.
MRI prostate: typically reserved for evaluation and diagnosis of malignancy.
Uroflowmetry for suspected BPH:
Urinary flow assessment is a non-invasive test that evaluates urodynamics. Two parameters that you will likely hear mentioned are Qmax (the maximum flow rate) and flow pattern, calculated with a void volume > 150ml. Different threshold values may be used (giving different sensitivities and specificities) and within-subject variability is seen.
Conservative management of BPH:
Consider watchful waiting in those with mild disease and symptoms. Medical and surgical therapies have complications that may be avoided or delayed.
In certain circumstances, a long-term catheter (changed every 3 months) is used for management.
Medical management of BPH:
Alpha-blockers (e.g. Tamsulosin): these inhibit the action of noradrenaline on the smooth muscle in the prostate resulting in reduced tone. Though they help with LUTS, alpha-blockers do not appear to prevent urinary retention or reduce the proportion that eventually needs surgery.
5-alpha reductase inhibitors (e.g. Finasteride): these reduce the production of dihydrotestosterone (DHT) which mediate androgen effects on the prostate. This leads to apoptosis of prostatic epithelial cells and reduction in prostate volume. They take up to 6 months to start having a clinically apparent effect. They have been shown to reduce the rate of acute urinary retention and the need for surgery.
Which group of medicines have been shown to reduce the rate of acute urinary retention and the need for surgery in BPH?
5-alpha reductase inhibitors (e.g. Finasteride) or Alpha-blockers (e.g. Tamsulosin)?
5-alpha reductase inhibitors (e.g. Finasteride)
Alpha-blockers help with LUTS, but do not appear to prevent urinary retention or reduce the proportion that eventually need surgery
Tamsulosin side effects (eyes?)
Intra-operative floppy iris syndrome (IFIS) may occur with alpha-blockers and the risk appears highest with tamsulosin. Ophthalmologists should be aware of the medication and avoid alpha-blockers in those awaiting cataract surgery
Tamsulosin side effects:
Problematic postural hypotension may limit its use. They are known to cause ejaculatory dysfunction but there is some data indicating improved erectile function. Intra-operative floppy iris syndrome (IFIS) may occur with alpha-blockers and the risk appears highest with tamsulosin. Ophthalmologists should be aware of the medication and avoid alpha-blockers in those awaiting cataract surgery.
Intra-operative floppy iris syndrome may occur with what group of medications?
Alpha-blockers - risk highest with Tamsulosin given for BPH
Is Tamsulosin fast or slow acting?
It is relatively fast-acting, with improvements seen in the first few days of use.
Is finasteride slow or fast acting?
Slow - may take up to 6 months to see the clinical effect
Finasteride side effects
Medications like finasteride can result in reduced libido, erectile dysfunction and less commonly ejaculatory dysfunction. It should be noted they cause a fall in serum PSA levels - this should be considered when testing for suspected prostate cancer.
Finasteride can cause a fall in what serum levels?
It should be noted they cause a fall in serum PSA levels - this should be considered when testing for suspected prostate cancer.
How do 5-alpha reductase inhibitors (e.g. Finasteride) work?
These reduce the production of dihydrotestosterone (DHT) which mediate androgen effects on the prostate. Finasteride does this via selective inhibition of 5α-reductase type 2. This leads to apoptosis of prostatic epithelial cells and reduction in prostate volume.
Surgical management of BPH: most common?
Transurethral Resection of the Prostate (TURP): is a common procedure in which a resectoscope is used to resect obstructing tissue. There are a number of complications that can occur. Retrograde ejaculation (up to 75%), urinary infection, need for urinary catheter are all relatively common. Occasionally clot retention, urinary incontinence, urethral stricture and erectile dysfunction may occur. A rare but serious early complication is TURP syndrome.
What is TURP?
Transurethral Resection of the Prostate (TURP): is a common procedure in which a resectoscope is used to resect obstructing tissue. There are a number of complications that can occur. Retrograde ejaculation (up to 75%), urinary infection, need for urinary catheter are all relatively common. Occasionally clot retention, urinary incontinence, urethral stricture and erectile dysfunction may occur. A rare but serious early complication is TURP syndrome.
What may complicate BPH?
Urinary retention may complicate BPH
Men presenting with acute urinary retention require ….
Men presenting with acute urinary retention require catheterisation.
Acute retention - BPH
Men presenting with acute urinary retention require catheterisation. Ensure you evaluate for infection and renal impairment that may complicate urinary retention.
Patients require urology review and work-up (particularly if they do not have an existing diagnosis). Typically on the first occasion, a patient may be started on an alpha-blocker and discharged with TWOC (trial without catheter) clinic follow-up. Recurrent retention typically indicates a need for surgical intervention.
Men with chronic retention should be catheterised particularly where there is renal impairment or …. Often surgery will be advised, though … …-catheterisation or a long-term catheter can be used.
Men with chronic retention should be catheterised particularly where there is renal impairment or hydronephrosis. Often surgery will be advised, though intermittent self-catheterisation or a long-term catheter can be used.
What is a very common condition affecting men in older age (usually over 50 years)?
Benign prostatic hyperplasia (BPH) is a very common condition affecting men in older age (usually over 50 years). It is caused by hyperplasia of the stromal and epithelial cells of the prostate. It usually presents with lower urinary tract symptoms.
The international prostate symptom score (IPSS) is a scoring system that can be used to assess the severity of …
The international prostate symptom score (IPSS) is a scoring system that can be used to assess the severity of lower urinary tract symptoms.
The initial assessment of men presenting with LUTS involves: (5)
Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate
Abdominal examination to assess for a palpable bladder and other abnormalities
Urinary frequency volume chart, recording 3 days of fluid intake and output
Urine dipstick to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology
Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference
Prostate-specific antigen (PSA) testing is known to be unreliable, with a high rate of false … (75%) and false … (15%).
Prostate-specific antigen (PSA) testing is known to be unreliable, with a high rate of false positives (75%) and false negatives (15%). False positive results may lead to further investigations, including invasive prostate biopsies, which have complications and may be unnecessary. False negatives may lead to false reassurance. Therefore, it is essential to counsel patients to make an informed decision about whether to have the test.
Common causes of a raised PSA are: (6)
Prostate cancer Benign prostatic hyperplasia Prostatitis Urinary tract infections Vigorous exercise (notably cycling) Recent ejaculation or prostate stimulation
Prostate exam: normal vs cancerous findings
A benign prostate feels smooth, symmetrical and slightly soft, with a maintained central sulcus
A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus
The medical options for BPH are … (2)
Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate
The general idea is that alpha-blockers are used to treat … symptoms, and 5-alpha reductase inhibitors are used to treat …. They may be used together where patients have significant symptoms and enlargement of the prostate.
The general idea is that alpha-blockers are used to treat immediate symptoms, and 5-alpha reductase inhibitors are used to treat enlargement of the prostate. They may be used together where patients have significant symptoms and enlargement of the prostate.
The surgical options for BPH:
Transurethral resection of the prostate (TURP)
Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
Holmium laser enucleation of the prostate (HoLEP)
Open prostatectomy via an abdominal or perineal incision
The notable side effect of alpha-blockers like tamsulosin is … ….
The notable side effect of alpha-blockers like tamsulosin is postural hypotension. If an older man presents with lightheadedness on standing or falls, check whether they are on tamsulosin and check their lying and standing blood pressure.
The most common side effect of … is sexual dysfunction (due to reduced testosterone).
The most common side effect of finasteride is sexual dysfunction (due to reduced testosterone).
The most common side effect of finasteride is … … (due to reduced testosterone).
The most common side effect of finasteride is sexual dysfunction (due to reduced testosterone).
What does a TURP involve?
Transurethral resection of the prostate (TURP) is the most common surgical treatment of BPH. It involves removing part of the prostate from inside the urethra. A resectoscope is inserted into the urethra, and prostate tissue is removed using a diathermy loop. The aim is to create a more expansive space for urine to flow through, thereby improving symptoms.
Major complications of TURP: (7)
Bleeding Infection Urinary incontinence Erectile dysfunction Retrograde ejaculation (semen goes backwards and is not produced from the urethra) Urethral strictures Failure to resolve symptoms
