BPH Flashcards
prostate depends on androgens (testosterone) for its development and functions
the prostate has a layer of tissue preventing it from growing outward, so it compresses inward on the urethra and leads to LOTUS (lower urinary tract symptoms), this leads to increased smooth muscle tone resistance, and a thickening of bladder wall which contracts even with small amounts of urine and leads to frequent urge to pee on a not full bladder
how is testosterone metabolized
from testosterone –> DHT(dihydrotestosterone)-which helps promote normal and healthy prostate growth
by the enzyme 5-alpha reductase
prostate enlargement doesnt’ typically cause problems until after age 65
drugs that worsen BPH
centrally acting anticholinergics (ex:benztropine) - because these will act like NE/Epi and encourage fight or flight restrictive response
anticholinergic drugs (antihistamines, decongestants, phenothiazines (ex: prochlorperazine), TCA’s (amitryptiline)
caffeine - a diuretic
diuretics
SNRi’s
testosterone products
to diagnose BPH, you need
digital rectal exam
prostate specific antigen
BPH doesnt lead to prostate cancer, but we test both of these because increased PSA can show up in prostate cancer so we want to rule cancer out with digital rectal exam by feeling and make sure its not hard
if a pt with BPH needs a drug for their cold /congestion, avoid giving decongestants. better option is a
nasal steroid or nasal decongestant (ex: oxymetazoline)
something thats more local and has less systemic exposure
BPH rarely progresses to get kidney damage. more common with prostate cancer. BPH is a benign growth. prostate cancer can completely block off the urethra and have urine flow back upstream
Treatment is typically watching and waiting if mild disease or surgery/minimally invasive procedures such as TURP (transurethral resection of the prostate)
They will be evaluated through questionairre AUASS (american urological association symptom score) or international prostate symptom score (I-PSS) are used
natural products for BPH
saw palmetto (although rated not effective) , rye pollen, pumpkin seeds, pygeum
- make sure if you see these, but they have no diagnosis, they get checked out rather than self treating.
lycopene for prostate cancer prevention not BPH
alpha-1 blockers are the first line treatment for moderate to severe symptoms
they work quick, but they don’t shrink the prostate gland
often used in combo with alpha 5 reductase inhibitors
or in combo with peripherally acting anticholinergics (tolterodine) when or beta 3 receptor agonists (mirabegron) in men without elevated post void residual (PVR) (< 250 - 300 ml required to use anticholinergics) urine and when LUTS are irritating
5 alpha reductase inhibitors and MOA
they decrease prostate size and PSA, but have a delayed onset. they decrease risk of urinary retention, improve sx, and decrease need for surgery by decreasing conversion of testosterone to DHT.
INDICATED FOR MEN WITH SYMPTOMATIC BPH and enlarged prostate
DO NOT USE in men with bladder outlet obstruction symptoms without prostate enlargement (BPH)
often used in combo with alpha 1 blockers
Types:
finasteride (proscar) 5 mg daily with or without tadalafil (combo is called entadfi) brand name propecia can be used (1mg daily, used for alopecia) - obviously pts should not be on both propecia and proscar
Dutasteride (avodart) - must be swallowed whole to avoid oropharynx irritation
there is a combo with tamsulosin is (Jalyn) 0.5 mg daily (pt must take jalyn at same meal daily)
Contraindicated in pregnancy or women of child bearing age, children
Warning: can increase risk of high grade prostate cancer
monitor : PSA, sx
SE: decreased libido (improved with time, usually back to normal in one year), ejaculation disturbances, breast enlargement/tenderness, rash,
tx for 6 months may be required for maximal efficacy
pts using alpha blockers are at risk of what eye condition
floppy iris syndrome developed during cataract surgery which inhibits the cataracts ability to dilate well.
- make sure that if surgery is planned, they delay their treatment until it’s finished
this is bc alpha receptors are in the eyes too
types of non selective alpha 1 blockers (more SE)
doxazosin (cardura, cardura XL) 1mg at bedtime (use XL at breakfast!!) and titrate up maxx 8 mg
terazosin - 1 mg at bedtime , titrate max 20 mg
Cardura can leave a ghost shell in stool!
types of selective alpha 1a blockers (less SE)
tamsulosin (flomax) 0.4 mg daily 30 min after same meal daily, max .80 mg daily
(+ dutasteride is Jalyn)
alfuzosin and silodosin are options that require dosing adjustments in poor renal fx
MOA: they inhibit the alpha 1 adrenergic receptors and cause relaxation of the smooth muscle in the prostate, bladder and neck. This reduces bladder outlet obstruction and makes it easier to pee.
SE: Dizziness, fatigue, HA, abnormal ejaculation (esp. with tamsulosin and silodosin), fluid retention, rhinitis (tamsulosin)
4-6 weeks may be required to assess effectiveness although it does start working right away. IT DOESN’T SHRINK PROSTATE OR PSA LEVELS
CI to alpha blockers
hepatic impairment with sildosin or alfuzosin
renal impairment with silodosin
never use sildosin or alfuzosin with strong CYP 3A4 inhibitors
