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- Y6 Renal and Urology > Benign prostatic hyperplasia (BPH) > Flashcards

Benign prostatic hyperplasia (BPH) Flashcards

1
Q

Define BPH.

A

Benign prostatic enlargement (BPE) resulting in bladder outflow obstruction causing LUTS (lower urinary tract symptoms).

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2
Q

What are the main 2 factors which cause LUTS in BPH?

A

Bladder outlet obstruction is predominantly due to 2 things:

  1. increase in benign prostatic tissue narrowing the urethral lumen
  2. increase in prostatic smooth muscle tone mediated by alpha-adrenergic receptors.
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3
Q

Which layers of the prostate are affected in BPH?

A

Hyperplasia of epithelial and stromal layers, particularly in the transitional zone. Increased stromal:epithelial ratio

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4
Q

How common is BPH?

A

Increases with age

~40% of men between 51-60yrs affected

1 in 4 men will be affected

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5
Q

What are the risk factors for BPH?

A
  • Age >50yrs and related hormonal changes
  • Genetic/FH
  • ethnicity: black > white > Asian
  • Smoking
  • Male pattern baldness
  • Metabolic syndrome
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6
Q

What are the clinical features of BPH?

A

Storage symptoms:

  • frequency
  • urgency
  • nocturia
  • incontinence

Voiding symptoms:

  • weak stream
  • dribbling
  • dysuria
  • straining

Complications like urinary retention or UTI (dysuria, fever)

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7
Q

What is the questionnaire used for storage and voiding symptoms?

A

International Prostate Scoring Symptoms (IPSS)

  • widely used, validated questionnaire covering the range of storage and voiding symptoms
  • Patients score each item from 0 to 5 according to the frequency with which the particular symptom is experienced
  • Total score will range from 0 to 35
  • The score should be re-evaluated over time to monitor disease progression and response to treatment
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8
Q

What is assessed in the IPSS?

A
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9
Q

How do you assess prostate size on DRE?

A
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10
Q

What investigations would you do for BPH?

A
  • *Urinalysis
  • *IPSS
  • *Voiding diary/Volume charting - help differentiate obstruction from irritative bladder pathology.
  • *Bloods - assess renal function - U&Es for CKD
  • *PSA - counsel on activities

Other: urologists consider:

  • DRE
  • Uroflowmetry - flow rate<15ml/s
  • Ultrasound/CT/MRI/cystoscopy - assess prostate size and shape
  • Urodynamic study - abnormal bladder voiding
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11
Q

Where is PSA produced? What is its function?

A

It is produced by the ductal and columnar acinar prostatic epithelial cells.

Its function is to liquefy the ejaculate in order to enable fertilisation to occur.

Large amounts are secreted into the semen and small amounts are found in the blood

Patients must be consented - high specificity, low sensitivity test

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12
Q

How do you manage BPH/voiding symptoms?

A

Conservative - Reassure; Fluid intake advice (reduce evening fluid intake), review medications

Medical - offer in bothersome symptoms

  • Alpha blockers (Tamsulosin, Alfuzosin, Doxazosin)
  • 5 alpha-reductase inhibitors (Finasteride, Dutasteride)
  • Other:
    • PDE-5 inhibitors (Tadalafil)
    • Anticholinergics (Tolterodine, Oxybutynin) - helps LUTS
    • Combination therapy - alpha blockers combined with any of the above

Surgical - for bothersome symptoms, based on prostate size. TURP gold standard.

  • _<_30g
    • Minimally invasive - Transurethral incision of the prostate (TUIP) - day case surgery
    • Moderately invasive - TURP (Transurethral Resection of Prostate)
  • 30-80g
    • Minimally invasive - prostatic urethral lift (PUL), transurethral microwave therapy (TUMT), and water vapor thermal ablation therapy.
    • Moderately invasive - TURP, transurethral vaporisation of the prostate (TUVP), laser enucleation or vaporisation, and aquablation
  • >80g
    • Open, laparoscopic, or robotic-assisted prostatectomy
    • Laser enucleation (holmium laser enucleation of the prostate [HoLEP])
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13
Q

Describe how BPH therapy works.

A

5-alpha-reductase inhibitors

Prostate capsule, stroma and bladder neck has many alpha adrenergic receptors. Alpah-1A receptors is predominant receptor in prostatic stromal tissue. Treatment of BPH symptoms is through reduction of the size of glandular component of the prostate. This is done by inhibition of DHT formation by 5a-reductase inhibitors AND through relaxation of SM tone with alpha-blockers.

Surgical

Reduces obstruction symptoms by reducing prostatic bulk.

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14
Q

What are the complications of BPH? What is the prognosis?

A

Progression of BPH

Urinary retention

Stones, haematuria

Renal insufficiency

Sexual dysfunction - a-blockers or 5-alpha-reductase inhibitors

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15
Q

What is the prognosis with BPH?

A

Majority should achieve at least moderate improvement of symptoms with management.

Most require ongoing therapy

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16
Q

What is acute urinary retention? What scan should be done?

A

Defined as painful inability to void, with relief of pain following drainage of the bladder.

Symptoms: gradual onset discomfort, increased frequency, nocturia, dribbling

Bladder scan residual - but diagnosis is made based on clinical examination

17
Q

What is shown here?

A

Bladder ultrasound scan - distended bladder

18
Q

What are the symptoms of bladder outlet obstruction? (BOO)

A
  • Frequency
  • Urgency
  • Nocturia
  • Dribbling
  • Hesitancy, intermittent flow , poor flow
19
Q

What is the prognosis with acute urinary retention?

A

50% of patients with spontaneous retention will experience a second episode in the next week or two and 70% within the next year.

20
Q

Name 3 causes of haematospermia.

A
  • prostatitis
  • prostate biopsy
  • urethritis
  • prostate malignancy - need to exclude
  • renal tract calculi
  • chlamydia
  • schistosomiasis
  • severe hypertension

Usually benign and self-limiting. If painful then usually due to prostatitis/urethritis.

21
Q

What investigations would you do for haematospermia?

A

Serum PSA

BP

MSU

Chlamydia test

NB: renal ultrasound would be done for haematuria rather than haematospermia

22
Q

If no cause is identified for haematospermia in a man >40yrs, what is the plan?

A

Refer to urology

Or man at any age with high PSA and suspicious DRE, >10 episodes haematospermia,

23
Q

What is the standard treatment for prostatitis?

A

14 days of quinolone (e.g. ciprofloxacin)

24
Q

What are the causes of LUTS?

A

BPH

Prostate cancer

Urethral stricture

Iatrogenic complication

Bladder pathology

Pelvic pathology

Neurological disease

25
Q

Describe urine flow rate in BPH vs normal.

A

Takes longer to void urine with lower flow rates

26
Q

What procedure is shown?

A

Urolift

27
Q

What procedure is shown?

A

REZUM

28
Q

What procedure is shown?

A

HoLEP

29
Q

What procedure is shown?

A

Millen’s prostatectomy

- Y6 Renal and Urology (22 decks)

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