Benign Prostatic Hypertrophy Flashcards
What is benign prostatic hyperplasia
Characterised by benign enlargement of the prostate
What does BPH result in
range of lower urinary tract symptoms
Name some lower urinary tract symptoms
Storage symptoms
- polyuria
- nocturne
- urgency
- incontinence
Voiding symptoms
- hesitancy
- intermittency
- involuntary interruption of voiding
- weak urinary stream
- straining to void
- dysuria
- sensation of incomplete emptying
Post-micturition symptoms
- post micturition dribbling
Name a score that you can use to assess the prostate
The International Prostate Symptom Score (IPSS)
How does the international prostate symptom score (IPSS) work
- Mild symptoms = 0-7
- Moderate symptoms = 8-19
- Severe symptoms = 20-35
describe the prevalence of LUTS and BPH
- increase in prevalent conditions in men that are over the age of 50 years in the UK
What are the short term consequences of BPH
- pain
- financial cost
- recurrent hospitalisation
- repeated GP visits
What are the long term consequences of BPH
- Likelihood of subsequent surgery
- increased risk of complications versus elective procedures
- risk of recurrent retention
name the 10 key priorities for implementation that NICE made for initial examination of LUTS
At initial assessment, offer men with LUTS an assessment of their general medical history to identify possible causes of LUTS, and associated comorbidities. Review current medication, including herbal and over-the-counter medicines, to identify drugs that may be contributing to the problem. - diabetes can be causing polyuria
a physical examination guided by urological symptoms and other medical conditions, an examination of the abdomen and external genitalia, and a digital rectal examination (DRE)
get them to do a frequency volume chart
Refer men for specialist assessment if they have LUTS complicated by recurrent or persistent urinary tract infection, retention, renal impairment that is suspected to be caused by lower urinary tract dysfunction, or suspected urological cancer.
Make sure men with LUTS have access to care that can help with their emotional and physical conditions and relevant physical, emotional, psychological, sexual and social issues. - erectile dysfunction and LUTS are oftne linked
Provide men with storage LUTS (particularly incontinence) containment products at point of need, and advice about relevant support groups
Offer men with storage LUTS (particularly urinary incontinence) temporary containment products (for example, pads or collecting devices) to achieve social continence until a diagnosis and management plan have been discussed.
Offer men with storage LUTS suggestive of overactive bladder (OAB) supervised bladder training, advice on fluid intake, lifestyle advice and, if needed, containment products.
If offering surgery for managing voiding LUTS presumed secondary to BPE, offer monopolar or bipolar transurethral resection of the prostate (TURP), monopolar transurethral vaporisation of the prostate (TUVP) or holmium laser enucleation of the prostate (HoLEP). Perform HoLEP at a centre specialising in the technique, or with mentorship arrangements in place.
If offering surgery for managing voiding LUTS presumed secondary to BPE, do not offer minimally invasive treatments (including transurethral needle ablation [TUNA], transurethral microwave thermotherapy [TUMT], high-intensity focused ultrasound [HIFU], transurethral ethanol ablation of the prostate [TEAP] and laser coagulation) as an alternative to TURP, TUVP or HoLEP (see above recommendation).
What is frequency volume chart
- what are they drinking and when are they passing urine
What are the three types of symptoms in LUTs
Voiding
Storage
post micturition
how many people over the age of 65 have bothersome LUTs
30%
Name the voiding symptoms
- weak or intermittent urinary stream
- straining
- hesitancy
- terminal dribbling
- incomplete emptying
Name the storage symptoms
- urgency
- frequency
- incontinence
- nocturia
Name the post micturition symptoms
- post-micturition Dribbling
What is a terminal dribble versus post micturition dribbling
- stream trickles of whereas post mictrutiion dribbling is where he thinks he has finished but then there is another escape of urine
What should you offer for initial assessment
- general medical and drug history
- Focused physical examination
- Abdominal examination and external genitalia and digital rectal examination (DRE)
What investigations in primary care should you offer
– Urine dipstick
– request patient completes frequency volume chart - this gives indication of voiding pattern and severity of symptoms
- IPSS score
– PSA test – if suspected BPH or prostate cancer
– Serum creatinine – only if indications of renal impairment
What does PSA stand for
prostate specific antigen
If PSA is more than 4ug
have to start thinking about prostate cancer
What is a frequency volume chart
- Voiding diaries are simple, non-invasive tools that are frequently part of the initial evaluation of patients complaining of LUTS, particularly those who have storage symptoms such as increased urinary frequency and incontinence.
- These diaries give an indication of the voiding pattern, the severity of symptoms and they add objectivity to the history.
What does the IPSS include
- bladder emptying
- frequency
- driblling
- continence
- weak urinary stream
- strain
- nocturia
- quality of life
How large is the average prostate
- 2cm in diameter
- approxiametly 20cc prostate
what should be assessed in a digital rectal examination
- Symmetry
- size
- firmness
- surface smoothness
- tenderness
- midline groove
what should also be assessed in a digital rectal examination
- Rectum and pelvis should also be assessed
- faecal loading or impaction
- rectal tumours and other pelvic massess may all be palpated when present
What is urinalysis used to identify
- haematuria
- glycosuira
- proteinuria
- pyuria
- presence of urinary nitrites and leucocytes
What can you use a dipstick test for
- sent for microscopy and culture
- microscopy may reveal bacteria, blood cells and cellular casts
When should you give a PSA
- LUTS are suggestive of bladder outlet obstruction secondary to BPE
- prostate feels abnormal on DRE
- concerned about prostate cancer
What are the secondary care investigations
- cystoscopy
- imaging of the upper urinary tract
- flow-rate measurement
- post void residual volume measurement - correlation between residual volume and how large the obstruction is
How do you measure your flow rate
- measure the speed and volume - can determine whether there is obstruction or not,
- over 15mls a second is normal
- under 15mls a second is not normal
What does the post void residual volume allow us to measure
- correlation between residual volume and how large the obstruction is
What are the aims of treatment in BPH
- Improve lower urinary tract symptoms - voiding and storage
- improve quality of life
- prevent severe BPE/BPO-related complications
what do you do if the symptoms are not bothersome versus if they are bothersome or if the IPSS is greater than 7
If they are not bothersome
- active surveillance - give reassurance, offer advice on lifestyle intervention and information on their condition, offer review if the symptoms change
If they are bothersome
- active intervention - conservative management/drug treatment or surgery
Name the conservative management for storage symptoms
- supervised bladder training
- advice on fluid intake
- lifestyle advice - less caffeine, carbonated drinks and alcohol
- containment products
Stress incontinence caused by prostatectomy
- offer supervised pelvic floor muscle training
Name the conservative management for voiding symptoms
- Offer intermittent bladder catheterisation before indwelling urethral or suprapubic catheterisation if LUTS cannot be corrected by less invasive measures.
- Explain to men with post micturition dribble how to perform urethral milking
What drug do you give if you have
- Moderate to severe LUTs
- LUTS and a prostate estimated to be larger than 30g or PSA greater than 1.4 ng/ml, and high risk of progression
- Bothersome moderate to severe LUTS, and a prostate estimated to be larger than 30g or PSA greater than 1.4 ng/ml
- Moderate to severe LUTs = offer an Alpha blocker
- LUTS and a prostate estimated to be larger than 30g or PSA greater than 1.4 ng/ml, and high risk of progression = offer a 5-alpha reductase inhibitor (5ARI)
- Bothersome moderate to severe LUTS, and a prostate estimated to be larger than 30g or PSA greater than 1.4 ng/ml = consider a combination treatment with an alpha blocker and a 5 alpha reductase inhibitor
How do 5 alpha reductase inhibitors work
- prevent the conversion of testosterone into dihydrotestosterone
- reduce androgenic drive of prostate
- reduction in prostate volume resulting in improved outflow
How do alpha 1 adrenergic receptors work
- in the prostate, urethra, bladder neck and detrusor muscle
- relaxation of smooth muscle resulting in improved urinary flow
Name an alpha blocker
tamulsosin
Name 5 alpha reductase inhibitors
Finasteride - inhibits 5AR Type II isoenzyme
dutasteride - is a dual inhibitor and inhibits both 5AR type I and type II isoenzymes
What is the first line treatment for patients with BPH
Prescribed for 98.5% of newly presenting patients in the UK
What is the advatnage of the alpha blockers
- work quickly
- well tolerated
- recommended for men with moderate to severe LUTs with no risk factors for progression
What is the disadvantage of alpha blockers
= No effect on prostate volume, PSA or on natural history of the disease - therefore the prostate will carry on increasing in size
= risk of retrograde ejaculation
= No effect on serious complications of BPH
= Large study (MTOPS) suggested no effect on underlying disease progression* over 4 years
What are the risk factors of progressive disease
- Age over 70 and LUTS
• Moderate to severe symptoms i.e.IPSS>7
• PSA>1.4ng/ml
• Prostate volume over 30ccs (i.e. feels enlarged on DRE)
• Flow rate < 12ml/sec
what does it mean if you have risk factors of progressive disease for BPH
- more likely to need surgery
- more likely to develop a complication
When after taking 5 alpha reductase inhibitors does LUTs start to improve
3-6 months
- takes time for the prostate to shrink
Who are 5 alpha reductase inhibitors recommended for
Recommended for men with moderate/severe LUTS at risk of BPH progression
What are the side effects of 5 alpha reductase inhibitors
relate to sexual function
What does combination therapy of 5 alpha reductase inhibitors and alpha blockers lead to
- improves symptoms
- inhibits disease progression
- improves IPSS
what does NICE recommend for storage symptoms despite treatment with alpha blocker
OAB = offer an anticholinergic drug along with alpha blocker
when should you review
- alpha blockers
- 5ARI
- anticholinergic
- alpha blockers = review at 4-6 weeks and then every 6-12 months
- 5ARI = review at 3-6 months and then every 6-12 months
- anticholinergic = review at 4-6 weeks until stable and then every 6-12 months
Who should you refer to a specialist
- Bothersome LUTS have not responded to conservative management or drug treatment
- LUTS complicated by recurrent or persistent urinary tract infection, or
- retention, or
- renal impairment you suspect is caused by lower urinary tract dysfunction or
- suspected urological cancer or - stress urinary incontinence
How do you manage acute urinary retention
- Acute = immediately catheterise
- offer an alpha blocker before withdrawing catheter and stay on treatment after removal
- if they still can’t pass urine catheterise again and assess for other treatments such as TURP
How do you manage chronic urinary retention
= catheterise and then prostate resection
- patients are usually unaware if chronic as they pass small amounts of urine
What is the gold standard operation for BPH
TURP
When should you offer surgery
- voiding symptoms are severe
- drug treatment and conservative management options have been unsuccessful or are not appropriate
What surgery treatment is for patients with overreactive bladder
- botulinum toxin
- cystoplasty
What are the surgical treatments for stress urinary incontinence
- implantation of an artificial sphincter
- intramural injectables
What are the positive and negative of the PSA test
- Not very sensitive - many false positives (1/3 with positive value actually have cancer)
- requires further biopsy testing that carries risk such as infection and bleeding
Name the causes of a raised PSA
- DRE
- Sex
- BPH
- infection
- UTI - have to wait 6 months for a PSA to normalise
- Age
- urethral cauterisation
- prostatic biopsy
What drug do you use for moderate to severe LUTS
- alpha blocker (Tamsulosin)
when would you use a 5a reductase inhibitor
- LUTS and prostate >30g
or - PSA > 1.4ug/ml and high risk of progression
When would you use both a alpha blocker and 5a reductase inhibitor
- Bothersome moderate to severe LUTS and prostate >30g
or - PSA>1.4ug/ml
Name 3 surgical treatments
- Transurethral resection of the prostate
- holmium laser enucleation of the prostate
- urolift
How does transurethral resection of the prostate work
- electric loop carves out prostate chips - gold standard
How does transurethral resection of the prostate work
- can cause erection issues (<14% become incompetent) and TURP syndrome (absorption into prostatic sinuses of fluids used to irrigate the bladder during the operation)
How does holmium laser enucleation of the prostate work
- Modern laser operation - becomes increasingly popular
- less risk of transfusion and erection issues and no TURP syndrome
How does UroLift work
- Purely mechanical – newest technique
- Preserves erections
