BENIGN PROSTATIC HYPERTROPHY Flashcards
a hyperplastic process, meaning there is an
increased number of cells.
Benign prostatic hyperplasia (BPH)
Most common benign tumor in men and its incidence is age related.**
Benign prostatic hyperplasia (BPH)**
Risk factors are poorly understood
Some studies suggest genetic predisposition and racial connection.
Pertinent anatomy of a patient with Benign Prostatic Hypertrophy.
(1) Prostate
(2) Bladder (neck)
(3) Urethra (prostatic)
Signs and symptoms
Symptoms can be related either to the obstructive component of the prostate or to the secondary response of the bladder to the outlet resistance (irritative).
Signs and symptoms
Obstructive**
(a) Hesitancy
(b) Decreased force and caliber of stream
(c) Sensation of incomplete bladder emptying
(d) Double voiding (urinating a second time within 2hr)
(e) Straining to urinate
(f) Postvoid dribbling
Signs and symptoms
Irritative symptoms
(a) Urgency
(b) Frequency
(c) Nocturia
Signs and symptoms
American Urological Association (AUA) symptom index
(a) Most important tool used in the evaluation of patients with BPH.**
(b) Should be calculated for all patients before starting therapy
1) Answers to seven questions quantitate the severity of obstructive or irritative complaints on a scale of 0-5**.
Physical exam
(a) Digital rectal exam**
1) Smooth firm elastic enlargement of the prostate
2) Induration should alert you to the possibility of cancer
(b) Neurologic exam
(c) Abdominal exam
1) Assess for a distended bladder
Differential Diagnosis
(1) Urethral stricture
(2) Bladder neck contracture
(3) Bladder stones
(4) Prostate cancer
(5) Urinary tract infection
(6) Bladder carcinoma
(7) Neurogenic bladder
Laboratory Findings
(1) Urinalysis
(a) To exclude infection or hematuria
(2) Prostate specific antigen test (PSA)
Imaging
(1) Should not routinely be ordered
(2) Upper tract imaging (CT or renal ultrasound)
(a) Recommended only in the presence of concomitant urinary tract disease or complications of BPH (hematuria, UTI, Chronic kidney disease, history of stone disease)
(3) Cystoscopy
(a) Only recommended to assist in determining the surgical approach in patients needing invasive therapy.
Treatment
Conservative
(1) Watchful waiting
(a) Patients with mild symptoms (AUA scores 0-7) should be managed by watchful waiting only.
(b) The risk of progression or complications is uncertain.
(c) Men with symptomatic disease, progression is not inevitable some men undergo spontaneous improvement or resolution of their symptoms.
(d) Men with moderate or severe symptoms can also be observed if they so choose
Treatment
Medical Therapy
(a) Alpha-blockers
1) Act against bladder outlet obstruction by relaxing smooth muscle in the bladder neck, prostate capsule, and prostatic urethra.
2) Examples: Terazosin, Tamsulosin
(b) 5-alpha-reductase inhibitors
1) Act by reducing the size of the prostate gland and in turn improves symptoms
2) Example: Finasteride
(c) Phosphdiesterase-5 inhibitors
1) Used in patients with erectile dysfunction with mild or moderate symptoms
2) Improve lower urinary tract symptoms
3) Example: Tadalafil
Treatment
Surgical therapy
(a) Absolute surgical indications include
1) refractory urinary retention (failing at least one attempt at catheter removal)
2) large bladder diverticula
3) Sequelae of benign prostatic hyperplasia: recurrent urinary tract infection, recurrent gross hematuria, bladder stones, or chronic kidney disease.
(b) Conventional
1) Transurethral resection of the prostate (TURP)
2) Transurethral incision of the prostate (TUIP)
3) Open simple prostatectomy
(c) Minimally invasive
1) Laser therapy
2) Transurethral needle ablation of the prostate (TUNA)
3) Transurethral electovaporization of the prostate
4) Hyperthermia
5) Implant, to open prostatic urethra
