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General surgery > Benign prostatic hyperplasia > Flashcards

Benign prostatic hyperplasia Flashcards

1
Q

Definition

A

Hyperplasia of stroma and epithelium of prostate

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2
Q

Most common location

A

Periurethral transition zone

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3
Q

Diagnostic features

A

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

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4
Q

What are the storage symptoms (3)

A

Frequency
Urgency
Nocturia

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5
Q

What are the voiding symptoms (6)

A 
Hesitancy
Intermittancy
Weak stream
Straining
Incomplete voiding
Post-void dribbling
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6
Q

Strong and weak risk factors (6)

A

Age= strong

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7
Q

History

A

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

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8
Q

Examination

A

DRE

Neurological

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9
Q

Investigations

A

Voiding diary
IPSS
?PSA
Urinalysis->MCS
UEC->kidney function, post-obstructive kidney, hydronephrosis
Uroflowmetry/urodynamics when considering surgery
Post void residual

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10
Q

When would US/CT of urinary tract be indicated

A

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.

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11
Q

What is the IPSS, questions and scoring

A 
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
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12
Q

Epidemiology

A

42% of men between the ages of 51 and 60 years, and 82% of men between the ages of 71 and 80 years.

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13
Q

Pathophysiology

A

+stromal to epithelial ratio

Obstruction due to prostatic (epithelial +) and dynamic due to + in stromal smooth muscle tone

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14
Q

Rationale for treatment options

A

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

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15
Q

Differential diagnosis

A 
Prostate cancer
Urethral obstruction
Bladder neck obstruction
Neurogenic bladder
Cystitis
Prostatitis
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16
Q

Management

A

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

17
Q

What is involved in behavioural management of BPH

A

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

18
Q

Prior to starting prostate medication what important condition needs to be considered

A

Floppy iris syndrome, which can cause technical difficulties during cataract surgery
Patients should be questioned about any potential eye surgery prior to initiating therapy.

19
Q

Counselling for alpha blockers

A

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

20
Q

Counselling for PDE-5 inhibitor

A

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

21
Q

If a nitrate is required and taking sildenafil

A

Allow at least 24 hours after last dose of sildenafil

22
Q

Counselling for 5-alpha reductase

A

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

23
Q

Surgical options for BPH

A

TURP
Bladder neck incision
Transurethral microwave thermotherapy
Radiofrequency ablation

24
Q

Consenting

A 
What you need to know
Complications
Preparation
Medical history of importance
Medications of importance
25
Q

Consenting for TURP

A

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

26
Q

Precipitants of acute urinary retention in BPH

A 
Diuresis
ALcohol
a1 stimulant
Anticholinergic
\+feces
Prostatitis, infarction
Neuropathic

General surgery (36 decks)

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