BPH Flashcards
What is the arterial blood supply of the prostate?
PROSTATIC ARTERY
What is the venous drainage of the prostate gland?
prostatic venous plexus -> internal iliac veins
-> internal vertebral venous plexus
What is the innervation of the prostate gland?
inferior hypogastric plexus
What are the causes of BPH?
- hormones -> increased estrogen & decreased testosterone
- growth factors -> secretion of intermediate peptide growth hormones
- genetic factors
What is the pathophysiology of BPH?
develops in middle transitional zone (outer peripheral zone in prostatic cancer)
hyperplasia -> hyperplastic nodule smooth & firm -> slit like urethral compression -> BOO (bladder outlet obstruction)
What are the clinical features of BPH?
STORAGE irritative symptoms
- frequency
- urgency
- urge incontinence
- nocturia
VOIDING obstructive symptoms
- straining
- hesitancy
- intermittency
- poor stream
- terminal dribbling
symptoms of superimposed infections
- dysuria
- hematuria
- constitutional symptoms
incomplete emptying & chronic or acute urinary retention
What is felt on DRE?
- symmetrically enlarged prostate
- smooth & firm
- nontender
- rubbery or elastic texture
What investigations should be done for patient with BPH?
- Urinalysis for all patients with LUTS
if abnormal findings -> urine culture
What is the importance of serum PSA level?
use in suspected prostate cancer
- 1.5 ng/mL -> enlarged prostate
- 4 ng/mL -> prostate cancer
What is the benefit of urodynamic studies?
helps identify the predominant type of LUTS
storage vs voiding
What are the indications of PVR?
- all patients with suspected BOO
- before treatment with antimuscarinic
- baseline before surgery
findings
- > 50ml is abnormal
- > 300ml -> urinary retention
How should BPH be managed?
1- watchful waiting
2- medical therapy -> alpha blocker for symptoms (zosins & tamsulosin)
-> 5 alpha reductase blockers to decrease size (Finasteride & Dutasteride)
3- surgical management
What are the side effects of alpha 1 blockers?
- orthostatic hypotension
- dizziness
- syncope
- tiredness
- peripheral edema
- headache
- ejaculatory problems
- nasal congestions
What are the side effects of 5 alpha reductase blockers?
- ED
- decreased libido
- gynecomastia
What are the indications of surgical intervention?
TRANSURETHRAL RESECTION OF THE PROSTATE in
- recurrent urinary retention
- recurrent UTIs
- renal insufficiency
- bladder calculi
- recurrent gross hematuria
- failure of medical therapy
What are the complications of transurethral resection of the prostate?
- retrograde ejaculation
- recurrent UTI
- urinary retention with bladder distention & bladder wall hypertrophy
- bladder calculi
- hydronephrosis
- chronic kidney disease
What is the preferred agent to be used in case of LUTS cause by BOO (bladder outlet obstruction)?
- small prostate (<40mL) or serum PSA <1.5ng/ml -> alpha blocker
- large prostate (>40mL) or serum PSA >1.5ng/ml -> 5-alpha reductase inhibitors
- severe symptoms or no response to therapy -> BOTH a blockers & 5-a reductase inhibitors
What is the preferred agent to be used in case of LUTS cause by OAB (over active bladder)?
antimuscarinic
What is the preferred agent to be used in case of LUTS caused by BOO & OAB?
alpha blocker & antimuscarinic
What is the preferred agent to be used in case of LUTS associated with erectile dysfunction?
phosphodiesterase 5 inhibitor
What are the mechanical causes of urinary retention?
- enlarged prostate
- urethral narrowing
- bladder neck obstruction
- extrinsic obstruction
- urethral/bladder trauma
What are the functional causes of urinary retention?
- detrusor underactivity &/or sphincter overactivity (neurogenic bladder or drug induced)
- detrusor-sphincter dyssynergia
- bladder neck dysfunction
- postoperative urinary retention
What are the clinical features of urinary retention?
acute
- sudden onset > 70 years
- painful inability to void
- suprapubic pain
- palpable bladder
- patient is restless and distressed
chronic
- more in males
- painless incomplete voiding
- may have palpable bladder
- overflow incontinence or nocturnal enuresis
How is urinary retention treated?
AUR -> SURGICAL EMERGENCY -> Bladder decompression (urethral or suprapubic)
treat the cause
- stricture -> dilatation
- BPH -> medication
What are the complications of urinary retention?
Acute -> renal failure
Chronic
- > UTI
- > vesicoureteric reflux -> hydronephrosis -> renal failure
- > urolithiasis
- > overflow incontinence
Bladder decompression
- > hematuria
- > transient hypotension
- > postobstructive diuresis
