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Year 3 > Benign prostatic hyperplasia (URO) > Flashcards

Benign prostatic hyperplasia (URO) Flashcards

1
Q

Define BPH.

A

Benign glandular and stromal hyperplasia of the transitional zone of the prostate

Hyperplasia of the epithelium and stromal prostate

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2
Q

What are the LUTS/bladder outlet obstruction in BPH due to? (2)

A
  • 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
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3
Q

What can the LUTS in BPH be defined into? (2)

A
  • storage symptoms - frequency, urgency, nocturia, incontinence
  • voiding symptoms - weak stream, dribbling, dysuria, straining
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4
Q

What does the prevalence of BPH increase with?

A

Age

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5
Q

Describe the epidemiology of BPH.

A
  • 42% of men 51-60 affected
  • 82% of men 71-80 affected
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6
Q

Describe the aetiology of BPH.

A
  • DHT is a potent prostatic growth factor
  • androgen/oestrogen imbalance as men age
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7
Q

What is the difference between pathological and clinical BPH?

A

The presence of symptoms means clinical vs pathological

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8
Q

Which drug is contraindicated in BPH and why?

A

Amitriptyline - can cause urinary retention

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9
Q

What is the purpose of PSA (BPH)?

A

PSA produced by luminal cells in prostate help liquify semen after ejaculation

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10
Q

What is the predominant receptor in prostatic stromal tissue?

A

Alpha-1 adrenergic receptor

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11
Q

How does prostatitis present? (4)

A
  • pain in perineum/penis/rectum/back
  • obstructive voiding symptoms
  • fevers and rigors
  • DRE –> tender, boggy prostate
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12
Q

How do we manage prostatitis? (2)

A
  • quinolone (e.g. ciprofloxacin) for 14 days
  • screening for STI
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13
Q

What are the clinical features of BPH? (4)

A
  • storage symptoms
  • voiding symptoms
  • UTIs
  • urinary retention (acute vs chronic)
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14
Q

What are the two types of LUTS in BPH?

A
  • voiding (obstructive) symptoms - often predominant
  • storage (irritative) symptoms
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15
Q

What are the voiding (obstructive) symptoms in BPH? (6)

A

SW HIPS

  • straining to urinate
  • weak stream
  • hesitancy (difficulty initiating urination)
  • intermittency
  • post-void dribbling
  • sensation of incomplete emptying
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16
Q

What are the storage (irritative) symptoms of BPH? (3)

A

FUN

  • frequency
  • urgency
  • nocturia
  • (dysuria)
17
Q

What does a fever with dysuria suggest (BPH)?

A

Complicated UTI

18
Q

What are the features of acute vs chronic urinary retention in BPH?

A
  • acute - severe suprapubic pain, distended palpable bladder
  • chronic - painless, frequency, nocturia, large distended painless bladder, signs of renal failure
19
Q

What might you find on examination in BPH?

A
  • 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
20
Q

What are the risk factors for BPH? (6)

A
  • age >50
  • Fx of BPH
  • non-Asian race
  • cigarette smoking
  • male pattern baldness
  • metabolic syndrome
21
Q

What are the first-line investigations for BPH? (4)

A
  • urinalysis
  • PSA (prostatic-specific antigen)
  • IPSS (symptom score questionnaire)
  • frequency/volume chart and voiding diary
22
Q

What is the gold-standard investigation for BPH?

A

Transrectal ultrasound-guided needle biopsy

23
Q

What might urinalysis show in BPH?

A
  • uncomplicated BPH - normal
  • pyuria (pus in urine) –> UTI
  • haematuria –> cancer
24
Q

What does PSA show in BPH?

A
  • elevation greater than age guideline - rough indicator for prostate size
  • increased PSA suggests underlying prostate cancer or prostatitis
  • results can guide men with LUTS
25
Q

What is the IPSS (BPH)?

A

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

26
Q

What is post-void volume a measure of in BPH? (1 + 3)

A

Urinary retention

  • <50mL = adequate bladder emptying
  • 50-100mL = normal in elderly
  • > 200mL = abnormal - due to incomplete bladder emptying or bladder outlet obstruction
27
Q

What does BPH feel like on DRE?

A

Smooth enlarged prostate + palpable midline groove

28
Q

What are some differential diagnoses for BPH? (8)

A
  • 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
29
Q

How do we manage emergency BPH?

A

Catheterisation

30
Q

How do we manage mild BPH?

A

Conservative management:

  • monitor symptom progression (watchful waiting)
  • lifestyle - avoid caffeine and alcohol, relax when voiding, control urgency, reduce fluids at night
31
Q

What is the first and second-line drug for BPH?

A
  • 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)
32
Q

What are some side effects of tamsulosin (a1-blocker in BPH)? (3)

A
  • dizziness
  • postural hypotension
  • may also cause retrograde ejaculation
33
Q

What are some side effects of finasteride (5-a-reductase inhibitor in BPH)? (4)

A
  • diminished libido
  • erectile dysfunction
  • gynaecomastia
  • decreases PSA levels
34
Q

What can we do if medical management does not work for BPH? (3)

A
  • 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
35
Q

What are some side effects of TURP for BPH? (4)

A
  • retrograde ejaculation - most common complication
  • TURP syndrome - hyponatraemia, fluid overload, glycine toxicity
  • urethral stricture/UTI
  • perforation of prostate
36
Q

What are some complications of BPH? (10)

A
  • 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
37
Q

What is the prognosis of BPH managed with medications vs surgery?

A
  • meds - mild Sx usually well-controlled with meds
  • surgery - most patients get significant relief from surgery

Year 3 (105 decks)

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