Benign prostatic hyperplasia (BPH) Flashcards
What is the category of symptoms caused by Benign prostatic hyperplasia?
lower urinary tract symptoms
How are lower urinary tract symptoms categories and which symptom lies in each category?
Categories - voiding, storage, post micturition
Voiding - A weak or intermittent urine stream Straining Hesitancy Terminal dribbling incomplete emptying
Storage - Urgency, The need to pass urine often (frequency) Incontinence Nocturia
Post micturition- Dribbling
Which score is used to assess lower urinary tract symptoms?
International Prostate Symptom Score (IPSS)
Score range of 0–35; higher score indicates worse symptoms
Mild symptoms - 0-7
Moderate symptoms- 8-19
Sever symptoms 20-35
In someone who has lower urinary tract symptoms, when should they be referred to a specialist? (4)
If the patient also has
- Recurrent or persistent UTI’s
- Urinary retention
- Renal impairment (suspected to be caused by lower urinary tract dysfunction)
- Suspected urological cancer
When someone presents with lower urinary tract symptoms what should your initial assessment include/ how do you diagnose the patient?
- Assessment of general medical history, including a review of current medication
General ‘focused’ physical examination including:
Abdominal examination (palpable or percussible bladder, enlarged or tender kidneys, tender suprapubic region for UTI) and external genitalia and digital rectal examination
(DRE)
Offer-
- Urine dipstick/ urinalysis (haematuria, urolithiasis, infection- UTI complicates prostatic hyperplasia)
- Frequency volume chart (voiding diary)- bothersome LUTS
- Creatinine and eGFR if renal impairment suspected (palpable bladder, nocturnal enuresis - bed wetting, Recurrent UTI, history of renal stones)
- Prostate specific antigen- offer information about PSA test (screen for prostatic cancer)
Bladder emptying (uroflow meter- low urinary flow rate <10-12mL/sec indicates failure in bladder emptying due to obstruction or detrusor muscle dysfunction)
Post void residual volume - assessed using an ultrasound. Post void volumes >24-50mL indicate impaired bladder emptying.
USS – Bladder enlargement, hydronephrosis, residual volume
IPSS to assess symptoms
When should a cystoscopy be offered?
Only in those with a sign of bladder abnormalities- storage symptoms
frank or microscopic haematuria
evaluate urological fistula
When should imaging of the upper urinary tract be offered?
Only in those with a sign of bladder abnormalities
renal dysfunction due to urological issues
Which tests should not be routinely offered to those with lower urinary tract infections?
Cystoscopy
Imaging of upper urinary tract
Flow rate measurement
Post void residual volume measurement
The treatment of mild to moderate lower urinary tract symptoms is based on the patients perception of symptoms- please explain further and describe the treatment options.
If the patient is not bothered by symptoms -
Offer active surveillance, life style advice
, review if symptoms change
If patient is bothered by symptoms -
Offer conservative management
- Supervised bladder training
- Advice on fluid intake
- Containment products (pads and collecting devices)
- urethral milking if terminal dribbling is symptom
Then drug treatment or surgery
Offer baseline assessment of symptoms e.g. IPSS
Which non pharmacological treatment options are available to those with LUS symptoms - voiding and storage?
- Supervised bladder training
- Advice on fluid intake
- Lifestyle advice
- Containment products
- Containment product as appropriate
- Intermittent bladder catheterisation before indwelling urethral or suprapubic catheterisation
(only if symptoms can not be corrected with other measures) - Men with post micturition dribbling should be shown how to perform urethral milking
If someone is suffering from incontinence caused by prostatectomy which additional non pharmacological treatment should be offered?
Supervised pelvic floor muscle training
Containment products
Which drugs are used to treat lower urinary tract symptoms (BPH) and what are the indications for each drug treatment?
Alpha blocker (Tamsulosin, Doxazosin, alfuzosin, terazosin) - Moderate to sever LUTS
5-Alpha reductase inhibitor (Finasteride) - LUTS and a prostate larger than 30g or PSA greater than 1.4ng/ml
Combination of the two- Bothersome moderate to sever LUTS, and a prostate larger than 30g or PSA greater than 1.4 ng/ml
Overactive bladder- anticholinergics if not appropriate or contraindicated give Mirabegron (beta 3 selective agonist)
Storage symptoms despite being treated with alpha blockers - give anticholinergics. Be carful with those with suspected bladder outlet obstruction
Nocturnal polyuria - late afternoon loop diuretics
What is the mechanism of action for 5-Alpha reductase inhibitor?
Decrease in dihydrotestosterone synthesis
Reduced androgenic drive of prostate
Reduction in prostate volume resulting in improved outflow
No effect on prostate volume, PSA or on natural history of
the disease
No effect on serious complications of BPH
What is the mechanism of action for Alpha blocker?
Blockade of α1-adrenergic
receptors in prostate, urethra, bladder neck and detrusor muscle causing smooth muscle relaxation
Relaxation of smooth muscle in prostate and bladder neck resulting in improved urinary flow
Name of the dual action 5-Alpha reductase inhibitor?
Dutasteride
What is the peak incidence age for BPH?
63-65
How much does a normal prostate weigh?
15-20 grams before the age of 40
After 40 the prostate begins to grow in size
If a patient presents with symptoms of BPH plus complications- which severity index would they be placed in?
Sever
What are the 3 main treatment goals when treating those with BPH?
- Control symptoms (3 point decrease in IPSS score)
- Prevent progression of BPH (prevent prostate getting larger)
- Reduce risk of complications
What are the complications of BPH?
Acute or chronic kidney failure Haematuria Over flow urinary continence Recurrent UTI Bladder stones Bladder diverticula
Before coming to a PSA test, what should patients not do?
Vigorous exercise and ejaculation
Give examples of second and third generation alpha 1 blockers (antagonists). What is the difference between the two classes?
Second generation- Terazosin and Doxazosin
Third generation- Tamsulosin and Silodosin
Third generation is specific for Alpha 1A. Second generation is not specific.
What are the side effects of second generation alpha 1 blockers?
Dizziness, syncope (particularly after first dose), Hypotension
What are the side effects of third generation alpha 1 blockers?
Fatigue, anejaculation, flu like symptoms, nasal congestion, floppy iris syndrome (rare)
What are the side effects of 5 alpha reductase inhibitors?
Sexual dysfunction (inc decreased libido), abdominal pain, dizziness, flatulence, headache, muscle weakness, gynecomastia
What is a contraindication for 5 alpha reductase inhibitors?
Pregnancy - do not have sex with someone who is using this drug while pregnant.
what are the indications for trans urethral resection of the prostate?
Failed voiding trials
Recurrent gross hematuria
Urinary tract infection
Renal insufficiency secondary to obstruction
When drug therapy proves insufficient especially if prostate is above 80g
What are the aide effects of trans urethral resection of the prostate?
urethral sphincter damage leading to incontinence
Infertility due to retrograde ejaculated
Urethral Strictures due to surgery scars
Erectile dysfunction
Bleeding after operation - should stop after 4 weeks
No change to lower urinary tract symptoms
What are the indications for a proctectomy?
When conservative and medical management fails
For very large prostates
>75g
Concomitant bladder stones
Complications of BPH
Which factors would suggest a patient may have a progressive disease?
Age over 70 with LUTS
• Moderate to severe symptoms i.e. IPSS > 7
• PSA > 1.4 ng/ml
• Prostate volume over 30ccs (i.e. feels enlarged
on DRE)
• Flow rate <12 ml/sec
What is the difference between the Finasteride and Dutasteride?
Finasteride inhibits 5AR (5 alpha reductate) Type II isoenzyme1
– Dutasteride is a dual inhibitor and inhibits both 5AR type I
and type II isoenzymes1
When is alpha reductase often recommended?
Recommended for men with moderate-to-severe LUTS,
with no risk factors for progression
When is 5 alpha reductase inhibitors often recommended?
Recommended for men with moderate/severe LUTS at risk of BPH progression3
When should you consider adding an anti-cholinergic to the treatment of someone with BPH?
When the patient has a over active bladder (definetly add it)
If the patient still has storage symptoms after being treated with an alpha blocker alone (consider adding it)
Which anticholinergic drugs are used in the treatment of BPH?
Darifenacin Solifenacin Tolterodine Oxybutynin Trospium Atropine
What are some common side effects of anticholinergic drugs?
Dry mouth, nausea, constipation, blurred vision, confustion
What are some contraindications for the use of anticholinergic drugs?
Narrow angle glaucoma
Urinary retention (>150mL)
Decreased gastric motility
How often should those on alpha blockers be reviewed?
Review at 4-6 weeks and then every 6-12 months
How often should those on 5ARI be reviewed?
Review at 3-6 months and then every 6-12 months
How often should those on Anticholinergics be reviewed?
Review at 4–6 weeks until stable, then every 6–12
months
When should men with LUTS be referred to a specialist?
Bothersome LUTS have not responded to conservative management or
drug treatment
LUTS complicated by recurrent or persistent urinary tract infection, or retention
renal impairment you suspect is caused by lower urinary tract dysfunction
Suspected urological cancer
Stress urinary incontinence
How should acute urinary retention be managed?
Immediately catheterisation
Offer an alpha blocker to men before withdrawing the catheter
How should chronic urinary retention be managed?
Men with chronic retention should be catheterised particularly where there is renal impairment or hydronephrosis.
Often surgery will be advised- e.g. transurethral resection of prostate
though intermittent self-catheterisation or a long-term catheter can be used.
When should surgery be offered to a patient?
Voiding symptoms are severe, or drug treatment and conservative
management options have been unsuccessful or are not appropriate.
How does the prostate size effect the surgery option made available to the patient?
All sizes- Monopolar or bipolar transurethral resections
Monopolar transurethral vaporisation of the prostate
Holmium laser enucleation of the prostate
Smaller than 30g- Transurethral incision of the prostate (as an alternative to the surgeries above)
Larger than 80g- transurethral resections of the prostate, transurethral vaporisation of the prostate, Holmium laser enucleation of the prostate
What are the surgical options for someone with detrusor overactivity?
Cytoplasty
Bladder wall injection with botulinum toxin
implanted sacral nerve stimulation
If not appropriate consider urinary diversion
What are the surgical options for someone with stress urinary incontinence?
Implantation of an artificial sphincter
intra mural injectables
Trans urethral resection of the prostate
What is the name of the condition caused when the foreskin is not returned back to its original position following a catheter insertion?
Paraphimosis
