Benign Prostatic Hypertrophy Flashcards
The functions of the prostate is to…
Contribute fluid to ejaculate
Constrict urethra during ejaculation to avoid contamination with urine
3 tissue types of the prostate are…
What are they responsive to?
- Epithelial tissue (glandular tissue) - responsive to testosterone
- Stromal tissue (smooth muscle) - lots of alpha1 receptors
- Capsule (outer shell)
The prostate is in close proximity of the bladder, which contains…
Muscarinic receptors
BPH occurs when…
Enlarged prostate starts to push against urethra, restricting flow of urine
BPH course overtime results in…
Bladder wall thickening, becoming irritable.
Bladder starts to contract even when containing small amount of urine
Overtime - bladder weakens + loses ability to empty itself completely, leaving urine behind
BPH has two main contributing factors, which include…
- Androgens - responsible for enlargement
- Age - decline in detrusor muscle strength
This androgen is particularly responsible for prostate enlargement:
Dihydrotestosterone (DHT)
Although androgens tend to decline with age, DHT…
Is likely increased, due to increased activity of intra-prostatic 5-alpha-reductase, converting testosterone to DHT
BPH symptoms may manifest as…
Storage issues - increased frequency, urgency, nocturia; terminal dribbling
Voiding issues - obstructive; weak/interrupted stream, difficulty initiating, straining, intermittency, pain while peeing
Post-micturition - post-void dribbling, sensation of incomplete bladder emptying
BPH symptoms usually appear ____ and…
Gradually - MAY worsen over time
BPH complications can include…
Overall decreased QoL
Overflow urinary incontinence/unstable bladder
Painful urinary retention - acute renal failure
Chronic renal failure - long-standing bladder outlet obstruction
Recurrent UTI’s
Bladder diverticula, stones
Persistent/intermittent gross hematuria
BPH assessment consists of…
International Prostate Symptom Score - questionnaire assessing severity
Urinalysis to rule out other causes
Digital rectal exam - smooth/nodular
Prostate specific antigen - baseline + progression
Prostate specific antigen is a predictor for…
Prostate size
Drugs that can exacerbate BPH include…
Androgens - encourage growth
Anticholinergics - cause further urinary retention
Stimulants - stimulate sphincter muscle
Non-pharm options to help with BPH may include…
Limting caffeine, alcohol, diuretic, anticholinergic use, and fluid intake in the evening
Bladder training - pelvic floor exercises
Physical activity
Avoiding/treating constipation
Anticholinergic use would be appropriate if there was urge incontinence
Pharmacological options to help with BPH include…
Alpha-1 blockers - 1st line
5-alpha-reductase inhibitors
PDE5 inhibitors
Potentially anticholinergics
Alpha1 blocker MOA to help with BPH is…
Blocking norepinephrine at alpha1 receptors in prostate gland, bladder neck, and urethra, causing vasodilation
Addresses dynamic component of obstruction, which can improve flow rates
These alpha1 blockers are uro-selective…
Alfuzosin, silodosin, tamsulosin - all equally effective at improving symptoms
Doxazosin, prazosin, terazosin are not
Do alpha1 blockers change the size of the prostate?
No - do NOT lower PSA
Time for benefit of alpha1 blockers is…
1-2 weeks
Improve, NOT eliminate
Effects of alpha1 blockers are…
Dose-related; including side effects
AE’s of alpha-1 blockers include…
Dizziness, fatigue, rhinitis, headaches
Decreased volume of ejaculate
Retrograde ejaculation
If someone has had cataract surgery and they are taking alpha1 blockers, there is a risk of…
Intraoperative floppy iris syndrome
Some potential CI’s/DI’s with alpha1 blockers include…
Anyone at risk of hypotension + falls
Caution in HF due to hypotension
3A4 inhibitors/inducers, or liver dysfunction
Dosage adjustment for renal impairment
5-alpha reductase inhibitors MOA is to…
Block conversion of intra-prostatic testosterone to DHT - site specific reduction of static component of obstruction
Improve obstructive symptoms due to prostate size
Do 5-alpha reductase inhibitors change prostate size?
Yes - can decrease PSA by 50%
Time for benefit of 5-alpha reductase inhibitors is…
Few months - up to 12 months for maximal effect
May slow progression or need for surgery
The 5-alpha-reductase inhibitors used are these two…
Dutasteride
Finasteride
AE’s of 5-alpha-reductase inhibitors are primarily…
Sexual dysfunction - ejaculatory dysfunction, loss of libido, impotence, gynecomastia
Pregnant or planning/child-bearing aged women should not handle 5-alpha-reductase inhibitors because…
It can cause birth defects in male fetus, where androgens are present
5-alpha-reductase inhibitors are correlated to cancer risk in that…
They reduce overall prostate cancer risk (small but statistically significant)
However, not approved to prevent prostate cancer - still for sx’s of BPH
PDE5 inhibitors may help for BPH in that…
Smooth muscle relaxation in and around prostate results in increased blood perfusion and may reduce BPH symptoms
This is the only PDE5 inhibitor indicated for BPH:
Tadalafil - daily use, NOT PRN
Onset of effect for tadalafil for BPH symptoms is…
About 4 weeks
Younger patients see best improvement
AE’s with tadalafil may include…
Headache, dyspepsia, lower back pain
Hypotension - caution with alpha-blockers
Same CI’s as when used for ED
Anticholinergics could be used for BPH if…
Overactive bladder symptoms are present
However note that these can exacerbate symptoms
If starting anticholinergics, course of action should be to…
Start low, go slow, frequently monitor.
Discontinue if no response or worsening
Time to benefit for anticholinergics is…
1 week to 1 month
Natural health products that may improve urinary symptoms are these two…
Pygeum
Beta-sitosterol
Best possible outcomes with pharmacotherapy for BPH are…
Less frequency + urgency
Greater force of stream
More complete emptying
As little impact as possible for AE’s
Overall greater QoL
Situations that prompt further therapies such as surgery include…
Failed pharmacotherapy
Failed trials of voiding
Renal insufficiency due to obstruction
Desire to stop meds, or too expensive
Recurrent hematuria, UTI’s, or bladder stones
