Benign Prostatic Hypertrophy Flashcards
What proportion of 50 year old men will have evidence of BPH and what proportion will have symptoms?
- 50% evidence
- 30% symptoms
What proportion of 80-year-old men have evidence of BPH?
80%
How does BPH occur in different ethnicities?
black > white > asian
What types of symptoms does BPH present with and what 4 groups can these be categorised into?
Lower urinary tract symptoms (LUTS)
- Voiding symptoms (obstructive)
- Storage symptoms (irritative)
- Post-micturition (dribbling)
- Complications
What are 5 voiding symptoms of BPH?
- Weak or intermittent urinary flow
- Straining
- Hesitancy
- Terminal dribbling
- Incomplete emptying
What are 4 storage symptoms of BPH?
- Urgency
- Frequency
- Urge incontinence
- Nocturia
What are 3 complications of BPH?
- UTI
- Retention
- Obstructive uropathy
What are 3 options for management of BPH?
- Watchful waiting
- Medication
- Surgery (TURP)
What are the 2 key types of medications used to treat BPH?
- Alpha-1a antagonists e.g. tamsulosin, alfuzosin
- 5 alpha-reductase inhibitors e.g. finasteride
What is the surgical procedure that can be used to treat BPH?
Trans-urethral resection of the prostate (TURP)
What is the mechanism of action of alpha-1 antagonists?
decrease smooth muscle tone (prostate and bladder)
What is the first line type of medication used for BPH?
alpha-1 antagonists (e.g. tamsulosin, alfuzosin)
What are 2 examples of alpha-1 antagonists used to treat BPH?
- Tamsulosin
- Alfuzosin
What are 4 adverse effects of alpha-1 antagonists?
- Dizziness
- Postural hypotension
- Dry mouth
- Depression
What is the mechanism of action of 5-alpha-reductase inhibitors?
- block the conversion of testosterone to dihydrotestosterone (DHT) which is known to induce BPH
- causes a reduction in prostate volume and hence may slow disease progression
- may also decrease PSA concentations up to 50%
What are 2 examples of 5 alpha-reductase inhibitor drugs?
- Finasteride
- Dutasteride
How long can it take 5-alpha reductase inhibitors to work?
symptoms may not improve for 6 months
What are 4 adverse effects of 5 alpha-reductase inhibitors?
- Erectile dysfunction
- Reduced libido
- Ejaculation problems
- Gynaecomastia
How can alpha-1 antagonists and 5 alpha-reductase inhibitors be used together?
use of combination thearpy supported by a key trial
How might a prostate feel that is suggestive of BPH?
enlarged, firm (not hard), smooth without nodules, clear median sulcus
What is a useful tool to use to assess the symptoms experienced by a patient with suspected BPH?
IPSS: International Prostate Symptom Score
What is the IPSS out of and what does the result indicate?
- result 0-35
- mild: 0-7
- moderate: 8-19
- severe: 20-35
What are 3 things that should be assessed on examinatino in suspected BPH?
- Examination of abdomen - check for palpable bladder
- DRE for tone of anal sphincter and pelvic floor
- Assess size/texture of prostate
What are 6 investigations that should be performed in suspected BPH?
- Urine dipstick and send MSU for microscopy and culture
- U+E and creatinine
- FBC
- LFTs (looking at ALP - bone metastasis)
- PSA
- Post-void residual bladder volume
What can LFTs be used for in BPH?
raised ALP could suggest prostate metastasis to bone
What combination of 2 investigations are said to be useful to differentiate BPH from prostate cancer?
DRE + PSA
What are 4 additional investigations that are sometimes indicated for BPH?
- Imaging e.g. ultrasound if suggestion of urinary tract obstruction
- Urine flow rate assessment
- Pressure studies
- Flexible cystoscopy
How can post-void residual bldder volume be assessed?
passing a catheter and measuring the volume, or ultrasound is a comfortable, non-invasive alternative
Currently in what scenario is the only time NICE recommend assessing post-void residual volume?
as part of specialist assessment
When is watchful waiting a judicious option for BPH?
when symptoms are minimal, provided that malignancy has been excluded
What are the three key things required for watchful waiting in BPH?
- Reassurance
- Education
- Monitoring
When should you offer first line drug treatment (alpha-adrenergic antagonists)?
Moderate to severe voiding symptoms - corresponding to IPSS of 8 or more
With what type of surgery should prescribers of tamsulosin be aware of and why?
cataract surgery - intra-operative floppy iris syndrome can occur with tamsulosin, where the iris billows out during the surgery
doesn’t affect long term outcome - can cause pain and prolong recovery period
What is the best alpha-1 adrenergic antagonist to use and why?
tamsulosin - selective for alpha-1a receptor, others are less selective
When might less specific alpha-blockers be useful in BPH?
if co-existent hypertension
What is a benefit of 5-alpha reductase inhibitors over alpha blockers?
reduce long term risk of acute retention or need for surgery
In what situations should 5-alpha reductase inhibitors be offered to treat BPH?
prostate estimated to be larger than 30g or PSA >1.4, and high risk of progression
When should you offer an alpha blocker plus 5-ARI?
moderate to severe LUTS not responding to monotherapy, with prostate estimated to be larger than 30g or PSA greater than 1.4
What are 2 situations when alpha-blockers should be avoided?
- Postural hypotension
- Micturition syncope
How long do studies suggest that alpha blockers work for?
4 years
What are 2 situations when you should admit a patient with BPH immediately?
- Acute retention of urine
- Acute kidney injury
What are 3 situations when you should make a 2 week wait referral in BPH?
- suspicion of prostate cancer based on nodular or firm prostate, or raised PSA level, or both
- culture-negative dysuria
- chronic urinary retention with overflow or night-time incontinence
What are 3 situations when you should make a referral (non-immediate or 2ww) to a specialist for BPH?
- Recurrent UTI
- Microscopic haematuria
- Failure to respond to treatment in primary care with poor quality of life assessed by IPSS
What is the PSA cut-off for men aged 40-49?
2 nanogram/mL or higher
What is the PSA cut-off for men aged 50-59?
3.0 or higher
What is the PSA cut off for age 60-69?
4.0 or higher
What is the PSA cut off for people aged 70 or older?
5.0 or higher
What is it important to do before performing PSA?
proper counselling of patient first
What are 6 causes of raised PSA?
- BPH
- prostatitis and UTI (postpone for at least 1 month)
- ejaculation (ideally not in the previous 48 hours)
- vigorous exercise (ideally not in previous 48 hours)
- urinary retention
- instrumentation of the urinary tract
In the case of prostatitis and urinary tract infection when can PSA be measured afterwards?
at least 1 month after treatment
How long should a patient go without ejaculation and vigorous exercise before PSA is measured?
48 hours
What is an aide memoir for the upper PSA limit?
(age-20) / 10
What proportion of men have prostate cancer with a PSA 4-10, and what proportion with PSA 10-20?
- 4-10: 33%
- 10-20: 60%
How can readings over time add more meaning to the PSA?
PSA velocity or PSA doubling time can be used
