Benign prostatic hyperplasia (URO) Flashcards
Define BPH.
Benign glandular and stromal hyperplasia of the transitional zone of the prostate
Hyperplasia of the epithelium and stromal prostate
What are the LUTS/bladder outlet obstruction in BPH due to? (2)
- static component - related to increase in benign prostatic tissue narrowing urethral lumen
- dynamic component - increase in prostatic smooth muscle tone mediated by alpha-adrenergic receptors
What can the LUTS in BPH be defined into? (2)
- storage symptoms - frequency, urgency, nocturia, incontinence
- voiding symptoms - weak stream, dribbling, dysuria, straining
What does the prevalence of BPH increase with?
Age
Describe the epidemiology of BPH.
- 42% of men 51-60 affected
- 82% of men 71-80 affected
Describe the aetiology of BPH.
- DHT is a potent prostatic growth factor
- androgen/oestrogen imbalance as men age
What is the difference between pathological and clinical BPH?
The presence of symptoms means clinical vs pathological
Which drug is contraindicated in BPH and why?
Amitriptyline - can cause urinary retention
What is the purpose of PSA (BPH)?
PSA produced by luminal cells in prostate help liquify semen after ejaculation
What is the predominant receptor in prostatic stromal tissue?
Alpha-1 adrenergic receptor
How does prostatitis present? (4)
- pain in perineum/penis/rectum/back
- obstructive voiding symptoms
- fevers and rigors
- DRE –> tender, boggy prostate
BPH characterised by voiding LUTS, prostatitis characterised by pain
How do we manage prostatitis? (2)
- quinolone (e.g. ciprofloxacin) for 14 days
- screening for STI
What are the clinical features of BPH? (4)
- storage symptoms
- voiding symptoms
- UTIs
- urinary retention (acute vs chronic)
What are the two types of LUTS in BPH?
- voiding (obstructive) symptoms - often predominant
- storage (irritative) symptoms
What are the voiding (obstructive) symptoms in BPH? (6)
SW HIPS
- straining to urinate
- weak stream
- hesitancy (difficulty initiating urination)
- intermittency
- post-void dribbling
- sensation of incomplete emptying
What are the storage (irritative) symptoms of BPH? (3)
FUN
- frequency
- urgency
- nocturia
- (dysuria)
What does a fever with dysuria suggest (BPH)?
Complicated UTI
What are the features of acute vs chronic urinary retention in BPH?
- acute - severe suprapubic pain, distended palpable bladder
- chronic - painless, frequency, nocturia, large distended painless bladder, signs of renal failure
What might you find on examination in BPH?
- DRE: prostate usually smoothly enlarged with a palpable midline groove
- feel against anterior wall of rectum (lies along posterior prostate)
- hard nodules could be a sign of prostate cancer
- NB: poor correlation between size and severity of Sx
What are the risk factors for BPH? (6)
- age >50
- Fx of BPH
- non-Asian race
- cigarette smoking
- male pattern baldness
- metabolic syndrome
What are the first-line investigations for BPH? (4)
- urinalysis
- PSA (prostatic-specific antigen)
- IPSS (symptom score questionnaire)
- frequency/volume chart and voiding diary
What is the gold-standard investigation for BPH?
Transrectal ultrasound-guided needle biopsy
What might urinalysis show in BPH?
- uncomplicated BPH - normal
- pyuria (pus in urine) –> UTI
- haematuria –> cancer
What does PSA show in BPH?
- elevation greater than age guideline - rough indicator for prostate size
- increased PSA suggests underlying prostate cancer or prostatitis
- results can guide men with LUTS
What is the IPSS (BPH)?
International Prostate Symptom Score: self-administered questionnaire with 8 questions (7 on Sx from 0-5):
- mild: 0-7
- moderate: 8-19
- severe: 20-35
1 additional question on QOL (bother score) scored from 0-6
What is post-void volume a measure of in BPH? (1 + 3)
Urinary retention
- <50mL = adequate bladder emptying
- 50-100mL = normal in elderly
- > 200mL = abnormal - due to incomplete bladder emptying or bladder outlet obstruction
What does BPH feel like on DRE?
Smooth enlarged prostate + palpable midline groove
What are some differential diagnoses for BPH? (8)
- overactive bladder (frequency, incontinence, nocturia)
- prostatitis (fever, suprapubic pain, tender enlarged prostate on DRE)
- prostate cancer (abnormal DRE, low free PSA)
- UTI
- bladder cancer (haematuria, suprapubic pain, bladder spasms with abnormal voiding, tobacco Hx)
- neurogenic bladder (Hx vascular disease, Parkinson’s, MS, DM with neuropathy)
- bladder underactivity
- urethral stricture
How do we manage emergency BPH?
Catheterisation
How do we manage mild BPH?
Conservative management:
- monitor symptom progression (watchful waiting)
- lifestyle - avoid caffeine and alcohol, relax when voiding, control urgency, reduce fluids at night
What is the first and second-line drug for BPH?
- 1st-line: alpha1-blockers (tamsulosin) - bind to a1 receptors to relax smooth muscle of bladder to decrease resistance to urinary flow
- 2nd-line/adjunct: 5-alpha-reductase inhibitors (finasteride) - reduced conversion of testosterone to DHT –> reduced prostate growth
- (phosphodiesterase-5 inhibitors e.g. sildenafil)
- (anticholinergic agent - tolterodine)
What are some side effects of tamsulosin (a1-blocker in BPH)? (3)
- dizziness
- postural hypotension
- may also cause retrograde ejaculation
What are some side effects of finasteride (5-a-reductase inhibitor in BPH)? (4)
- diminished libido
- erectile dysfunction
- gynaecomastia
- decreases PSA levels
What can we do if medical management does not work for BPH? (3)
- TUIP (transurethral incision of prostate) - less destruction=less risk to sexual function, but smaller benefit than TURP
- TURP (transurethral resection of prostate) - standard for prostate size<80g and LUTS, or TUVP (transurethral vaporisation of prostate)
- open prostatectomy
What are some side effects of TURP for BPH? (4)
- retrograde ejaculation - most common complication
- TURP syndrome - hyponatraemia, fluid overload, glycine toxicity
- urethral stricture/UTI
- perforation of prostate
What are some complications of BPH? (10)
- BPH progression
- recurrent UTI due to residual urine
- acute/chronic urinary retention –> bladder stones
- sexual dysfunction
- bladder hypertrophy –> obstructive renal failure –> post-obstructive diuresis
- stone development
- hydronephrosis
- TURP complications - TURP syndrome (hyponatraemia, fluid overload, glycine toxicity)
- haematuria
- overactive bladder
What is the prognosis of BPH managed with medications vs surgery?
- meds - mild Sx usually well-controlled with meds
- surgery - most patients get significant relief from surgery
