Benign prostatic hyperplasia Flashcards
Definition
Hyperplasia of stroma and epithelium of prostate
Most common location
Periurethral transition zone
Diagnostic features
Presence of risk factors
Storage symptoms->frequency, urgency, nocturia
Voiding symptoms->weak stream, hesitancy, intermittency, straining, incomplete voiding, post void dribbling
?Chronic or acute urinary retention
What are the storage symptoms (3)
Frequency
Urgency
Nocturia
What are the voiding symptoms (6)
Hesitancy Intermittancy Weak stream Straining Incomplete voiding Post-void dribbling
Strong and weak risk factors (6)
Age= strong
History
Storage and voiding
Fever, pain, dysuria->UTI
Hematuria->bladder/prostate Ca
Neurological, diabetes->other cause of LUTS
Surgeries, catheterisation
Diuretics, anticholinergics, alpha agonists
CV/renal disease->polyuria, polydipsia
Examination
DRE
Neurological
Investigations
Voiding diary
IPSS
?PSA
Urinalysis->MCS
UEC->kidney function, post-obstructive kidney, hydronephrosis
Uroflowmetry/urodynamics when considering surgery
Post void residual
When would US/CT of urinary tract be indicated
Urinary tract imaging with ultrasound or CT is not recommended unless the patient has 1 of the following: chronic retention, recurrent UTI/haematuria, renal insufficiency, urolithiasis, or a history of prior urinary tract surgery.
What is the IPSS, questions and scoring
International prostate symptom score Mild 1-7 Mod-severe 8-35 QOL due to urinary symptoms Incomplete emptying Frequency Intermittency Urgency Weak stream Straining Nocturia
Epidemiology
42% of men between the ages of 51 and 60 years, and 82% of men between the ages of 71 and 80 years.
Pathophysiology
+stromal to epithelial ratio
Obstruction due to prostatic (epithelial +) and dynamic due to + in stromal smooth muscle tone
Rationale for treatment options
The predominant alpha-1 receptor in prostatic stromal tissue is the alpha-1A receptor. Treatment of symptomatic BPH is mainly accomplished via the reduction of the size of the glandular component following inhibition of the formation of dihydrotestosterone (DHT) by 5-alpha-reductase inhibitors and through relaxation of smooth muscle tone with alpha-blockers. [5] Select surgical intervention (e.g., transurethral resection) alleviates symptoms of urinary obstruction by reduction of prostatic bulk
Differential diagnosis
Prostate cancer Urethral obstruction Bladder neck obstruction Neurogenic bladder Cystitis Prostatitis
Management
Referral to urologist
Acute
mild disease (IPSS score 0-7) with no significant bother
1st line: watchful waiting
adjunct: behavioural management programme
mild disease (IPSS score 0-7) with significant bother
1st line: alpha-blocker->tamsulosin
1st line: phosphodiesterase-5 (PDE-5) inhibitor->sildenafil
1st line: non-steroidal anti-inflammatory drug (NSAID)->celecoxib
adjunct: behavioural management programme
moderate and severe disease (IPSS score 8-35)
1st line: alpha-blocker
1st line: phosphodiesterase-5 (PDE-5) inhibitor
1st line: non-steroidal anti-inflammatory drug (NSAID)
adjunct: behavioural management programme
1st line: 5-alpha-reductase inhibitor->finasteride
adjunct: behavioural management programme
2nd line: combination 5-alpha-reductase inhibitor with alpha-blocker or PDE-5 inhibitor or NSAID
adjunct: behavioural management programme
Ongoing
abnormal rectal examination and/or elevated PSA or PSA velocities and/or progressive BPH and/or with complications
1st line: surgical referral
prostate
What is involved in behavioural management of BPH
Limitation of fluids/alcohol/caffeine, bladder training focused on timed and complete voiding, and treatment of constipation
A review of the patient’s medication list->avoid/modify medications that may impact symptoms of BPH->antihistamine, diuretics, antidepressants, decongestants
Prior to starting prostate medication what important condition needs to be considered
Floppy iris syndrome, which can cause technical difficulties during cataract surgery
Patients should be questioned about any potential eye surgery prior to initiating therapy.
Counselling for alpha blockers
Tamsulosin, terazosin
MOA: Block alpha1 receptors, relaxing smooth muscle in the bladder neck and prostate, and decreasing resistance to urinary flow. Terazosin also arterial/venodilator
Precautions: volume depletion (+orthostatic hypotension)
Cataract surgery, elderly (hypotension)
SE: abnormal ejaculation, first dose/orthostatic hypotension, dizzy, nasal congestion, urgency, HA, weakN, drowsy
Counselling- caution standing up, may be dizzy. If drowsy caution heavy machinery. Tell your opthalmologist
Stop if no improvement in BPH symptoms after 4-6 weeks of maximal dose
Counselling for PDE-5 inhibitor
Sildenafil->when BPH and erectile dysfunction
MOA: Sexual stimulation increases cyclic guanosine monophosphate (cGMP) levels, resulting in smooth muscle relaxation, inflow of blood to the corpus cavernosum and penile erection.. These agents inhibit the breakdown of cGMP by phosphodiesterase 5 (PDE5), increasing blood flow to the penis during sexual stimulation.
CI: concomitant use of NO agents->risk of hypotension or MI. Caution use of other antihypertensives. Caution: CV, renal, liver, eye
SE: Rash, diarrhea, UTI, abnormal vision, HA, dizzy, flushing,
dyspepsia, nasal congestion
Counselling:
Do not take with nitrates
May cause visual disturbances and dizziness
Tell doctor if sudden vision loss/hearing
Caution use with other antihypertensives
If a nitrate is required and taking sildenafil
Allow at least 24 hours after last dose of sildenafil
Counselling for 5-alpha reductase
Finasteride
MOA: Inhibit 5‑alpha-reductase, which converts testosterone to dihydrotestosterone (a potent cellular androgen that stimulates prostate growth). They reduce prostate size and improve symptoms and urinary flow rate.
SE: Impotence, negative libido, ejaculation disorder
Counselling:
Women considering pregnancy not to touch
Effect depends on prostate size
May take > 6 months for symptoms to improve
Long term use + risk of urinary retention and need for surgery
After 1 year, PSA levels reduce by 50%
Breast cancer has been reported
Surgical options for BPH
TURP
Bladder neck incision
Transurethral microwave thermotherapy
Radiofrequency ablation
Consenting
What you need to know Complications Preparation Medical history of importance Medications of importance
Consenting for TURP
Required to relieve blockage of urine caused by enlarged prostate
Insertion of pencil like device into penis, cutting away small sections of the prostate via a camera (draw picture)
Given local anaesthetic/general, making numb
Takes about 2 hours
Catheter will remain for 1-2 days until pass trial of void- to drain bladder and any blood loss
May be initially painful to urinate, but soon will get better
Post-op remain home for 2-3 weeks, no driving for 2 weeks, avoid sex for 2 months
Complications: Anaestehsia->respiratory, cardiovascular, allergy Hemorrhage, infection Impotence Retrograde ejaculation (no issues, infertility) Hematuria->usually settled by 3 weeks Incontinence->initially UTI Retention->clots->reason for catheter Irrigation->hyponatremia, hypervolemia Recurrence
Fast from midnight
Come on day
Any medical conditions: asthma, epilepsy, diabetes, MS, COAD, heart/kidney
Medication: lithium, warfarin, aspirin, steroids
Past ops, trouble with anaesthesia, allergies
Precipitants of acute urinary retention in BPH
Diuresis ALcohol a1 stimulant Anticholinergic \+feces Prostatitis, infarction Neuropathic
