Benign Prostatic Hypertrophy

Question 1

Clinical Features

Answer 1

Voiding / Obstruction - predominant in bladder outlet obstruction (BOO) secondary to BPH
Hesitancy, Weak Stream, Intermittence, Straining
Storage - r/o overactive bladder (OAB)
Urgency, Frequency, Urgency Incontinence, Nocturia
Postmicturition
Dribbling, Incomplete Emptying

Question 2

What symptom score can be used?

Answer 2

International Prostate Symptom Score (IPSS)

Question 3

Risk Factors

Answer 3

Age, obesity, diabetes, family history

Question 4

DDx

Answer 4

• Prostate CA
• Prostatitis
• Bladder Stones
• Interstitial Cystitis
• UTI
• Urethral stricture

Question 5

Physical Exam Maneuvers

Answer 5

Suprapubic abdominal tenderness
Neuro (motor/sensory of perineum and lower limbs)
DRE

Question 6

Investigations

Answer 6

Urinalysis +/- culture (r/o infection)
PSA
PVR if considering anticholinergics (eg. storage symptoms suggesting OAB)

Question 7

Management of Nocturnal Polyuria

Answer 7

Voiding/Frequency chart 2-3 days
If urine output ≥3L
Decreased intake, aim for urine output 1L
If nocturnal urine output >33% nocturnal polyuria diagnosed
Consider Desmopressin

Question 8

Management of Mild (IPSS < 8) BPH

Answer 8

Fluid restriction particularly prior to bedtime
Avoidance of alcohol, caffeine, spicy foods
Avoidance/monitoring of some drugs (e.g., diuretics, decongestants, antihistamines, antidepressants)
Timed or organized voiding (bladder retraining)
Pelvic floor exercises
Avoidance or treatment of constipation

Question 9

Management of Moderate - Severe (IPSS > 8) BPH Include side effects.

Answer 9

Alpha-blockers: Side effects: H/A, dizziness, Orthostatic hypotension, retrograde ejaculation (ejaculation failure)

5-alpha reductase inhibitors: For larger prostates (eg. DRE>30mL or PSA>1.5 ng/dL), Side effects: Decreased libido, erectile dysfunction, ejaculatory disorder

Combo alpha blocker + 5 alpha reductase inhibitor if symptomatic LUTS + prostate enlargement (>30 cc). After 6-9 months of combination therapy, consider stopping alpha blocker

Also options of : antimuscarinics, beta 3 agonist (mirabegron), and anticholinergics

Question 10

Management of LUTS + erectile dysfunction

Answer 10

PDE-5 inhibitors for LUT symptoms + erectile dysfunction

Question 11

Management of Storage Symptoms. What do you add if voiding symptoms.

Answer 11

Antimuscarinics and beta 3 agonists caution if obstruction or PVR >250mL. Use in combination with alpha blocker if voiding + storage symptoms.

Question 12

Management of nocturnal polyuria

Answer 12

Desmopressin

Question 13

Indications for surgery

Answer 13

Recurrent or refractory urinary retention
Recurrent UTI
Bladder Stones
Recurrent hematuria
Renal dysfunction secondary to BPH
If medical management fails

Question 14

Preoperative testing

Answer 14

Cystoscopy +/- transrectal or transabdominal U/S

Question 15

List 2 types of surgeries. List indications and the ADRs.

Answer 15

Monopolar – Transurethral resection of the prostate (M-TURP)
Moderate to severe LUTS due to BPH in pts with prostate volume 30-80 cc
ADRS: Retrograde ejaculation (65%), ED (6.5%), urinary retention (4-13%), hematuria, TUR syndrome, infection, incontinence
Prostatectomy (open simple vs. laser)
Can be used for prostates > 80cc

Question 16

Indications for referral

Answer 16

Recurrent UTI
Hematuria
Prior genitourinary sx / trauma
Increased PSA >10/10 plus Abn DRE
Abnormal DRE
Suspicion of urinary retention
Meatal stenosis
Pelvic pain

Question 17

When to do a PSA

Answer 17

Symptoms or strong family history 
IF 
Life expectancy > 10 years 
Would change management 
After discussion with patient about risks and benefits

Question 18

Lifestyle management of BPH

Answer 18

Stop antihistamines 
Stop decongestants 
Stop NSAIDS
Stop excess fluids
Stop Caffeine
Stop Alcohol

Question 19

General pharm treatment algorhithm for BPH

Answer 19

1. Alpha blocker (tamsulosin)
2. 5 alpha reductase inhibitors (Finasteride
3. 1 and 2
4. Antimuscarinics (mirabegron)
5. 1 and 4
6. Phosphodiesterase type 5 inhibitors (Tadalafil)