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Benign Prostatic Hypertrophy Flashcards

1
Q

What proportion of 50 year old men will have evidence of BPH and what proportion will have symptoms?

A
  • 50% evidence
  • 30% symptoms
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2
Q

What proportion of 80-year-old men have evidence of BPH?

A

80%

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3
Q

How does BPH occur in different ethnicities?

A

black > white > asian

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4
Q

What types of symptoms does BPH present with and what 4 groups can these be categorised into?

A

Lower urinary tract symptoms (LUTS)

  1. Voiding symptoms (obstructive)
  2. Storage symptoms (irritative)
  3. Post-micturition (dribbling)
  4. Complications
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5
Q

What are 5 voiding symptoms of BPH?

A
  1. Weak or intermittent urinary flow
  2. Straining
  3. Hesitancy
  4. Terminal dribbling
  5. Incomplete emptying
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6
Q

What are 4 storage symptoms of BPH?

A
  1. Urgency
  2. Frequency
  3. Urge incontinence
  4. Nocturia
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7
Q

What are 3 complications of BPH?

A
  1. UTI
  2. Retention
  3. Obstructive uropathy
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8
Q

What are 3 options for management of BPH?

A
  1. Watchful waiting
  2. Medication
  3. Surgery (TURP)
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9
Q

What are the 2 key types of medications used to treat BPH?

A
  1. Alpha-1a antagonists e.g. tamsulosin, alfuzosin
  2. 5 alpha-reductase inhibitors e.g. finasteride
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10
Q

What is the surgical procedure that can be used to treat BPH?

A

Trans-urethral resection of the prostate (TURP)

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11
Q

What is the mechanism of action of alpha-1 antagonists?

A

decrease smooth muscle tone (prostate and bladder)

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12
Q

What is the first line type of medication used for BPH?

A

alpha-1 antagonists (e.g. tamsulosin, alfuzosin)

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13
Q

What are 2 examples of alpha-1 antagonists used to treat BPH?

A
  1. Tamsulosin
  2. Alfuzosin
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14
Q

What are 4 adverse effects of alpha-1 antagonists?

A
  1. Dizziness
  2. Postural hypotension
  3. Dry mouth
  4. Depression
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15
Q

What is the mechanism of action of 5-alpha-reductase inhibitors?

A
  • 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%
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16
Q

What are 2 examples of 5 alpha-reductase inhibitor drugs?

A
  1. Finasteride
  2. Dutasteride
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17
Q

How long can it take 5-alpha reductase inhibitors to work?

A

symptoms may not improve for 6 months

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18
Q

What are 4 adverse effects of 5 alpha-reductase inhibitors?

A
  1. Erectile dysfunction
  2. Reduced libido
  3. Ejaculation problems
  4. Gynaecomastia
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19
Q

How can alpha-1 antagonists and 5 alpha-reductase inhibitors be used together?

A

use of combination thearpy supported by a key trial

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20
Q

How might a prostate feel that is suggestive of BPH?

A

enlarged, firm (not hard), smooth without nodules, clear median sulcus

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21
Q

What is a useful tool to use to assess the symptoms experienced by a patient with suspected BPH?

A

IPSS: International Prostate Symptom Score

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22
Q

What is the IPSS out of and what does the result indicate?

A
  • result 0-35
    • mild: 0-7
    • moderate: 8-19
    • severe: 20-35
23
Q

What are 3 things that should be assessed on examinatino in suspected BPH?

A
  1. Examination of abdomen - check for palpable bladder
  2. DRE for tone of anal sphincter and pelvic floor
  3. Assess size/texture of prostate
24
Q

What are 6 investigations that should be performed in suspected BPH?

A
  1. Urine dipstick and send MSU for microscopy and culture
  2. U+E and creatinine
  3. FBC
  4. LFTs (looking at ALP - bone metastasis)
  5. PSA
  6. Post-void residual bladder volume
25
Q

What can LFTs be used for in BPH?

A

raised ALP could suggest prostate metastasis to bone

26
Q

What combination of 2 investigations are said to be useful to differentiate BPH from prostate cancer?

A

DRE + PSA

27
Q

What are 4 additional investigations that are sometimes indicated for BPH?

A
  1. Imaging e.g. ultrasound if suggestion of urinary tract obstruction
  2. Urine flow rate assessment
  3. Pressure studies
  4. Flexible cystoscopy
28
Q

How can post-void residual bldder volume be assessed?

A

passing a catheter and measuring the volume, or ultrasound is a comfortable, non-invasive alternative

29
Q

Currently in what scenario is the only time NICE recommend assessing post-void residual volume?

A

as part of specialist assessment

30
Q

When is watchful waiting a judicious option for BPH?

A

when symptoms are minimal, provided that malignancy has been excluded

31
Q

What are the three key things required for watchful waiting in BPH?

A
  1. Reassurance
  2. Education
  3. Monitoring
32
Q

When should you offer first line drug treatment (alpha-adrenergic antagonists)?

A

Moderate to severe voiding symptoms - corresponding to IPSS of 8 or more

33
Q

With what type of surgery should prescribers of tamsulosin be aware of and why?

A

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

34
Q

What is the best alpha-1 adrenergic antagonist to use and why?

A

tamsulosin - selective for alpha-1a receptor, others are less selective

35
Q

When might less specific alpha-blockers be useful in BPH?

A

if co-existent hypertension

36
Q

What is a benefit of 5-alpha reductase inhibitors over alpha blockers?

A

reduce long term risk of acute retention or need for surgery

37
Q

In what situations should 5-alpha reductase inhibitors be offered to treat BPH?

A

prostate estimated to be larger than 30g or PSA >1.4, and high risk of progression

38
Q

When should you offer an alpha blocker plus 5-ARI?

A

moderate to severe LUTS not responding to monotherapy, with prostate estimated to be larger than 30g or PSA greater than 1.4

39
Q

What are 2 situations when alpha-blockers should be avoided?

A
  1. Postural hypotension
  2. Micturition syncope
40
Q

How long do studies suggest that alpha blockers work for?

A

4 years

41
Q

What are 2 situations when you should admit a patient with BPH immediately?

A
  1. Acute retention of urine
  2. Acute kidney injury
42
Q

What are 3 situations when you should make a 2 week wait referral in BPH?

A
  1. suspicion of prostate cancer based on nodular or firm prostate, or raised PSA level, or both
  2. culture-negative dysuria
  3. chronic urinary retention with overflow or night-time incontinence
43
Q

What are 3 situations when you should make a referral (non-immediate or 2ww) to a specialist for BPH?

A
  1. Recurrent UTI
  2. Microscopic haematuria
  3. Failure to respond to treatment in primary care with poor quality of life assessed by IPSS
44
Q

What is the PSA cut-off for men aged 40-49?

A

2 nanogram/mL or higher

45
Q

What is the PSA cut-off for men aged 50-59?

A

3.0 or higher

46
Q

What is the PSA cut off for age 60-69?

A

4.0 or higher

47
Q

What is the PSA cut off for people aged 70 or older?

A

5.0 or higher

48
Q

What is it important to do before performing PSA?

A

proper counselling of patient first

49
Q

What are 6 causes of raised PSA?

A
  1. BPH
  2. prostatitis and UTI (postpone for at least 1 month)
  3. ejaculation (ideally not in the previous 48 hours)
  4. vigorous exercise (ideally not in previous 48 hours)
  5. urinary retention
  6. instrumentation of the urinary tract
50
Q

In the case of prostatitis and urinary tract infection when can PSA be measured afterwards?

A

at least 1 month after treatment

51
Q

How long should a patient go without ejaculation and vigorous exercise before PSA is measured?

A

48 hours

52
Q

What is an aide memoir for the upper PSA limit?

A

(age-20) / 10

53
Q

What proportion of men have prostate cancer with a PSA 4-10, and what proportion with PSA 10-20?

A
  • 4-10: 33%
  • 10-20: 60%
54
Q

How can readings over time add more meaning to the PSA?

A

PSA velocity or PSA doubling time can be used

GP (43 decks)

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