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Oral Board Mastery > BPH > Flashcards

BPH Flashcards

1
Q

In the initial evaluation of patients with bothersome LUTS possibly attributed to BPH, clinicians SHOULD obtain:

A

GUIDELINE STATEMENT 1

Medical history (sexual hx, meds, overall fitness and health)

Physical exam

IPSS/AUA SS (symptom burden)

UA (bacteria, rbc, wbc, glucose, protein)

Options:

PVR, uroflow, pressure flow studies

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2
Q

What first options for management of LUTS SHOULD patients be counselled?

A

GUIDELINE STATEMENT 2

behavioral/lifestyle modifications (limit fluids qHS, with travel, caffeine, ETOH, spicy foods, chocolate, avoid constipation, increase activity, weight loss, kegels, timed voiding, double voiding, PFME +/- biofeedback)

medical therapy if additional tx necessary

referral for surgical evaluation (if seen by PCP)

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3
Q

After initiating treatment, when SHOULD providers assess response and how should patients be evaluated?

A

GUIDELINE STATEMENT 3

4-12 weeks after

(alpha blockers, beta 3 agonists, PDE5I and AC, shorter acting → as early as 4 weeks, longer acting 5-ARIs 3-6 mo)

IPSS/AUA SS

Uroflow and PVR

Consider Global Subjective Assessment

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4
Q

Patients with bothersome LUTS/BPH who elect initial medical management and do not have symptom improvement and/or intolerable side effects SHOULD:

A

GUIDELINE STATEMENT 4

undergo further evaluation and change medical management or proceed to surgery

consider UDS to confirm BOO vs. DO

trial additional medication classes

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5
Q

Prior to intervention for LUTS/BPH what SHOULD clinicians consider assessment of:

A

GUIDELINE STATEMENT 5

prostate size and shape via TRUS or abdominal US, cysto, cross sectional imaging (MRI/CT) if studies available (w/in 12 mo preferred)

volume: ellipsoid volume (height x length x width x 0.523)

*DRE and PSA unreliable in estimating size

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6
Q

Prior to sx intervention for BPH, what office based test SHOULD be done if it has not been done prior?

A

GUIDELINE STATEMENT 6

PVR

“large” PVR > 300 is worth monitoring, may warrant UDS vs. surgery

*does not seem to be a strong predictor of AUR

GUIDELINE STATEMENT 7

Uroflow

*must void 150 cc, no valsalva, characterize voiding dysfunction

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7
Q

Prior to surgical intervention for BPH/LUTs, what can be CONSIDERED if diagnostic uncertainty exists?

A

GUIDELINE STATEMENT 8

Pressure flow studies (UDS)

contractility, Qmax, peak voiding pressures, BOO

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8
Q

When considering minimally invasive sx for LUTS/BPH, what SHOULD clinicians counsel patients is possible in regards to outcomes?

A

GUIDELINE STATEMENT

treatment failure and need for secondary treatments

objective failure (urinary retention, reduction of Qmax, increased PVR, infection)

subjective failure (worsening IPSS, increase in duration of f/up or tx)

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9
Q

When treating BPH medically which class of medications would you start with and name all the medications in that class? What is the choice of medication bae on?

A

GUIDELINE STATEMENT 10

alpha blockers for bothersome, moderate-severe LUTS/BPH

alfuzosin, doxazosin, silodosin, tamsulosin, terazosin

GUIDELINE STATEMENT 11

choice of alpha blocker should be based on age, comorbidities, and different adverse effects (EjD, BP)

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10
Q

Which alpha blockers have the highest risk of orthostatic hypotension?

A

terazosin and doxazosin

tamsulosin best for BP, followed by alfuzosin and silodosin

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11
Q

What are alpha blockers with lowest risk of EjD?

A

doxazosin or terazosin

alfuzosin

*due to paralysis of smooth muscles in wall of prostatic ducts → anejaculation

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12
Q

What other surgical procedures warrant caution or further consideration in regards to starting alpha blockers?

A

GUIDELINE STATEMENT 12

with planned cataract surgery there is risk of intraoperative floppy iris syndrome

should be discussed with optho or defer initiation

discontinue 4-7 days prior to cataract, but does not completely eliminate IFIS

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13
Q

When is 5-ARI monotherapy appropriate for treatment of LUTS/BPH? What is the mechanism of action? what types are utilize?

A

GUIDELINE STATEMENT 13

prostatic enlargement > 30 cc on imaging, a PSA > 1.5, or palpable enlargement on DRE

Finasteride 5 mg (isoenzyme II only)

Dutasteride 0.5 mg (isoenzyme I and II)

*act via inhibition of alpha reductase (testosterone → DHT) leading to less available DHT → reduction in overall androgenic growth stimulus → atrophy and shrinkage (15-25% in 6 mo)

Reduction in prevalence of prostate cancer (RRR 25%, but more high grade prostate cancer dx)

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14
Q

What is meant by combination therapy? Utilization of which medication as part of this regimen can reduce the risk of urinary retention and need for surgery?

A

MTOPS trial

GUIDELINE STATEMENT 14

5ARIs alone or in combo with alpha blockers are recommended as tx option to prevent progression of LUTS/PGH and/or reduce risk of urinary retention and need for future prostate surgery

GUIDELINE STATEMENT 18

5-ARI in combo with alpha blockers should be offered as treatment only when prostate volume > 30 cc, PSA > 1.5, or palpable enlargement on DRE

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15
Q

What should clinicians counsel as adverse effects of 5-ARIs?

A

GUIDELINE STATEMENT 15

sexual side effects, physical side effects, low risk of CaP

MTOPS→ decline in sexual and ejaculatory function, decreased libido

Gynecomastia, dementia, depression, DMII (2x risk), post finasteride syndrome

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16
Q

What other indication can 5 ARIs be utilized for?

A

GUIDELINE STATEMENT 16

reduce intraoperative bleeding in peri- or postoperative need for blood txf after TURP or surgical intervention for BPH

17
Q

Besides alpha blockers or 5ARIs what is an additional daily therapy for BPH/LUTs?

A

GUIDELINE STATEMENT 17

5 mg tadalafil should be discussed as a treatment option irrespective of comorbid ED

*can offer similar results seen with tamsulosin but does not improve UDS parameters

18
Q

When are anticholinergics/beta-3 agonists indicated in treatment of BPH/LUTS?

A

GUIDELINE STATEMENT 19

alone or in combo with alpha blockers, may be offered as option with moderate-severe predominant storage LUTS

*AUR low in selected patients

PVR obtained, precautions used (gastric emptying, GI motility issues, narrow angle glaucoma, dementia)

GUIDELINE STATEMENT 20

beta-3-agonists in combo with alpha blocker may use used as treatment option in patients with moderate-severe predominant storage LUTS

19
Q

Which combination therapy should not be prescribed for treatment of LUTS/BPH?

A

GUIDELINE STATEMENT 21

5 mg tadalafil and alpha blockers, offers no advantages in symptom improvement over either agent alone

no advantage of tadalafil and finasteride either

20
Q

What are important elements to consider for TOV and what should patients be conselled?

A

GUIDELINE STATEMENT 22

prescribe alpha blockers prior to voiding trial for AUR

GUIDELINE STATEMENT 23

newly treated for AUR with alpha blockers, complete at least 3 days of tx before TOV

GUIDELINE STATEMENT 24

patients who pass TOV for AUR from BPH are at higher risk of recurrent AUR

21
Q

What are indications to proceed to surgery for BPH?

A

GUIDELINE STATEMENT 25

renal insufficiency secondary to BPH
refractory urinary retention due to BPH
recurrent UTIs
recurrent bladder stones or gross hematuria due to BPH
with LUTS/BPH refractory or unwilling to use other therapies

22
Q

How do you manage a bladder diverticulum in the presence of BPH?

A

GUIDELINE STATEMENT 26

should not perform surgery solely based on presence of asx bladder diverticulum; however, evaluation for BOO should be considered

(indications for surgery are same for BPH in general, treat BOO as indicated)

23
Q

Surgical treatment options for BPH

A
24
Q

List sx treatment options for BPH and recommenations:

A

GUIDELINE STATEMENT 27/28

TURP, monopolar or bipolar depending on expertise

GUIDELINE STATEMENT 29

open, lap, robotic assisted prostatectomy for large to very large prostates

GUIDELINE STATEMENT 30

TUIP, prostates < 30 cc, lower rate of RE or blood txf

GUIDELINE STATEMENT 31

Bipolar TUVP (rollerball, vaportrode, loop, button) → improved blood loss

GUIDELINE STATEMENT 32

PVP should be offered using 120 W or 180 W platforms (anticoagulation)

GUIDELINE STATEMENT 33/34

PUL considered volumes 30-80 with absence of obstructing median lobe as an option for patients that desire preservation of erectile and ejaculatory function

GUIDELINE STATEMENT 35

TUMT (transferring energy to tissue creating heat, special cooling cath)

GUIDELINE STATMENT 36/37

WVTT (Rezum–water vapor thermal therapy) for volumes 30-80 cc as an option for patients that desire preservation of erectile and ejaculatory function

GUIDELINE STATMENT 38

TUNA IS NOT RECOMMENDED

GUIDELINE STATEMENT 39

HoLEP or ThuLEP considered depending on expertise and prostate size (less txf, AC)

GUIDELINE STATEMENT 40

Robotic water jet (RWT) prostates 30-80 cc (TRUS map and transurethral waterjet robotic hand-piece)

25
Q

What is the role for PAE in BPH?

A

GUIDELINE 41

not supported for routine treatment, benefit over risk remains unclear, not recommended outside clinical trials

26
Q

Hematuria can be deemed due to BPH when:

A

GUIDELINE STATEMENT 42

all other causes have been excluded, 5ARIs may be appropriate and effective tx alternative for refractory hematuria due to BPH

*suppression of vascular endothelial growth factor (VEGF), decreased angiogenesis and bleeding

*role of PAE in mgmt. of refractory hematuria evolving

27
Q

What surgical options should be utilized for patients who are at higher risk of bleeding?

A

GUIDELINE STATEMENT 43

HoLEP, PVP, ThuLEP

28
Q

Important questions to ask for BPH patient history?

A

IPSS/AUA SS

SHIM

symptom duration
bother
frequency of sxs
frequency of incontinence
how many times does patient void daily
weakened stream, stranguria, hesitancy, intermittency, sensation of incomplete emptying, nocturnal enuresis
volume of fluid intake/caffeine
hematuria, dysuria, hx STD or UTIs
urgency
leakage with activity or cough

29
Q

Important aspects of PE for BPH?

A

cognition, neuro

extremities for edema and pulses

general appearance (obesity)

abdomen (bladder distention, flank)

penis (curvature, meatus)

testis

perineum (sensation)

anal tone

DRE (prostate)

30
Q

DDX of worsening LUTS in men?

A

Neurologic (MS, SCI, CVA, Parkinson’s)

BNO

CIS, bladder cancer

UTI

Urinary retention

Urethra stricture

Polydipsia

OAB

Nocturnal polyuria

31
Q

How do you monitor post obstructive diuresis?

A

Insert foley (urinary retention)

Frequent orthostatic (BP/HR) vitals to assess for conversion to POD

Ask patient to drink fluids to thirst

Monitor UOP

Intermittent serum chemistries to assess recovery of renal function

32
Q

Definition of post obstructive diuresis? tx?

A

a polyuric and natriuretic state after relief of obstruction

clinical dx UOP > 200 mL/hr for 2 h or > 3L in 24 h

physiologic diuresis usually self limited

strict monitoring of UOP, weight, electrolytes (mag, phosphate, urea, creatinine) q 4-q12h

collect urine for urinary sodium, potassium, osmo to determine type, spot Na > 40 mEq/L imply renal tubular injury and can lead to pathologic POD

drink to taste (avoid excess)

if unable to drink give D5 ½ NS maintenance plus replace ½ cc per cc with D5 ½ NS

Can get US in 48h to confirm resolution of hydro

If remove foley, need to teach CIC

Consider UDS and sx

Can trial medical therapy with backup of CIC

33
Q

How do you manage post TUR syndrome?

A

Abort surgery

place large bore foley overfilling balloon to compress bladder neck with traction (if unable to finish surgery or bleeding)

administer Lasix 20 mg to induce free water clearance

Perform blood gas requesting serum Na to asses hyponatremia

Transfer to ICU for continuous vitals and seizure precautions

Calculate free water excess in case hypertonic saline needed

34
Q

What are urinary storage symptoms?

A

nocturia

SUI

UUI

frequency

urgency

35
Q

risks of transurethral prostate surgery?

A

urethral stricture
infection
bleeding/txfn
long term prostate regrowth and repeat procedure
ED
ejaculatory dysfunction
injury to adjacent structures
bladder neck contracture

36
Q

IPSS

A
37
Q

What is initial tx for LUTS s/p TURP?

A

UA and UCX

if no UTI → observation (some irritative sxs and UUI atributoed to DO secondary to prostatic obstuction, healthing resected fossa, and irritate urthera post instrumentation)

Uusally 4-6 weeks, improves tover 12 weeks

stress reduction, timed voiding, fuluid restriction, dietary adjustments

Oral Board Mastery (35 decks)

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