BPH Flashcards
what is the pathophysiology of BPH?
With age, there is an increase in the activity of the enzyme, 5-alpha reductase. This results in an increase in dihydrotestosterone (DHT) and oestrogen. DHT acts on androgen receptors within the prostate causing hyperplasia, with oestrogen also contributing to hyperplasia.
what is the difference in the area affected in BPH vs prostate cancer?
Prostatic growth in BPH predominantly affects the peri-urethral region of the prostate called the transition zone, resulting in compression of the prostatic urethra.
In contrast, prostate cancer usually occurs in the peripheral zone.
what are the risk factors for BPH?
Increasing age: particularly >50 years old
Family history
Ethnicity: more common in Afro-Caribbean men; black > white > asian
Diabetes
Obesity: due to increased circulating oestrogens
what are primary investigations you would preform when suspecting BPH?
Urinalysis: the presence of pyuria suggests infection
Prostate-specific antigen (PSA): predicts prostate volume, progression and may suggest cancer if significantly raised; remember BPH can also raise PSA
U&Es: renal failure if significant obstruction
International Prostate Symptom Score (I-PSS): a 7-symptom questionnaire with an additional bother score to predict progression and outcome
what further imaging and investigations would you consider for BPH
Renal tract ultrasound: if acute urinary retention is suspected, will help identify hydronephrosis (backflow of pressure). Ultrasound can also estimate prostate size
Flow rate: non-invasive test, suggests obstructive cause if rate <20ml/second
Urodynamics: invasive and measures bladder pressures and muscle activity. Reserved for men aged <50 years, or elderly patients with equivocal flow rate
Flexible cystoscopy: not recommended unless symptoms are associated with haematuria, or bladder calculi are suspected
WHAT is the management for BPH symptoms which are not bothersome?
Conservative: treat constipation reduce caffeine and fluid intake medication review bladder retraining
what is the management of bothersome symptoms not ready for surgery?
- a1 antagonist: tamsulosin, relaxes the sooth muscle.
- se: postural hypotension, dizziness, dry mouth, depression
2.5-α reductase inhibitors: inhibits DHT formation to reduce prostate size, thus slowing progression (unlike α-blockers); e.g. finasteride [4]. Takes up to 6 months to work
Side effects: reduced libido, erectile dysfunction, reduced ejaculate volume, gynaecomastia
- sildenafil- used for severe LUTS
which bothersome symptoms may indicate the need for surgery?
RUSHES
recurrent refractory urinary retention
UTIs- recurrently
Stones in bladder
Elevated creatinine due to outflow obstruction
Symptom deterioration despite maximal medical therapy
what are the different surgical options for treating BPH?
Prostate <30 g: transurethral incision of the prostate (TUIP)
Prostate 30-80 g: transurethral resection of the prostate (TURP)
Prostate >80 g: open prostatectomy
what are complications related to BPH?
Acute urinary retention
Urinary tract infections
Renal dysfunction: due to obstructive uropathy; backflow of pressure from the prostate blocking the urethra results in hydronephrosis
Haematuria
Bladder stones: secondary to urinary stasis
what are complications related to BPH surgery?
Retrograde ejaculation: commonest complication
Erectile dysfunction
TURP syndrome: a life-threatening triad of fluid overload, dilutional hyponatraemia and neurotoxicity due to systemic absorption of irrigation fluids during TURP procedure
