BPH

Question 1

What kind of diagnosis are the following:
1) BPE
2) BPO
3) BPH
4) BOO
5) LUTS

Answer 1

1) BP Enlargement - Clinical
2) BP Obstruction - Clinical
3) BP Hyperplasia - Histological
4) Bladder Outflow Obstruction - Urodynamic
5) LUTS - Lower urinary tract symptoms

Question 2

What are:
1) Storage Symptoms
2) Voiding Symptoms
3) Post Micturition Symptoms

Answer 2

1) Altered bladder sensation, Frequency, Nocturia, Urgency, Incontinence
2) Hesitance, Intermittency, Slow Tream, Spraying, Straining, Terminal Dribble
3) Incomplete emptying, Post micturition dribble

Question 3

i) RFS for BPH
ii) Predictors for worsening LUTS ?
iii) Predictors for prostate growth

Answer 3

i) Age, Androgen Theory, Metabolic theory - obesity, DM, dyslipidaemia, Osterogens

ii) Initial Flow <10 ml /second, Inreasing age >70 years old,

iii) Raised baseling prostate volume (>40cc) , Raised PSA (>1.4 mcg/L), Residual volume >150 ml

Question 4

Who can you watch and wait for?
Why watch and wait?

Answer 4

50-60% of patients don’t have symptom progression/ avoid Rx side effects

• Low bother/ Without RFs (Low prostate vol, Low RV, Low PSA etc.)

Question 5

i) What does tamsulosin act upon?
ii) How does finasteride work?

Answer 5

i) Tamsulosin - 5alpha 1A receptor.
ii) Induces apoptosis of prostate epithelial cells. Decreases Volume by between 18-28%. QMAX improvement 1-2ml/sec. IPSS improvement 15-30%

Question 6

What did MTOPS study show?

Answer 6

That baseling PSA / Prostate volume is a predictor for symptomatic worsening.

Reduced risk of BPH related progression or AUR (Combination>Finasteride>Doxazosin)
Improvement in symptoms (Combination > Finasteride > Doxazosin)

Recommend combination therapy in large prostates + Mod/severe LUTS +PSA >1.6

Combination therapy effective in preventing BPH progression events

Question 7

What did the Olmsted County Study show?

Answer 7

Six year prospective cohort study - random sample of men

PSA >1.6
Pros Vol >30 ml
Moderate LUTS

4 x more likely to undergo BPH management

Question 8

What does COMBAT study show?

Answer 8

Combination therapy vs Monotherapy (Either 5ari/5a1A)

IPSS Improvement (Combibnation>Dutasteride>Tamsulosin)
QMAX Improvement ( DCombination>Dutasteride>Tamsulosin)
PV reduction (Combination>Dutasteride>Tamsulosin)

Combi therapy + Dutasteride equal in preventing AUR/Surgery.

Question 9

Are anticholinergics safe in BPE?

Answer 9

Yes - Neptune study shows in combination with tamsulosin.

Question 10

PDE5i for BOO

Answer 10

Symptom benefit

No benefit in QMax/UDS

Question 11

What predictors are there for Higher risk of complication in TURP?

Answer 11

Resection time >90 mins
Large prostate >50 ml s
AUR with catheter
Age >80
Black

Question 12

When would you offer 5aRI?

Answer 12

PV > 30 cc / PSA > 1.4 mcg/L

Question 13

What does the PLESS study show?

Answer 13

Finasteride vs Placebo:
Reduced volume by 18%
IPSS imrpoved by 1.6
FR improved by 2 ml/second
Risk of surgery/ acute retention decreased by 50%