BPH Flashcards
Tissue Types in Prostate
Epithelia tissue (aka – glandular tissue) – produces prostate secretion (androgens promote growth)
responsive to testosterone
Stromal tissue (aka – smooth muscle)
rich with α1-receptors
The capsule (outer shell) – Connective tissue, and smooth muscle, some alpha receptors
Close proximity of bladder with muscarinic receptors
Functions of the Prostate
To contribute fluid to ejaculate
To constrict urethra during ejaculation to avoid contamination with urine
What is BPH?
Hyperthrophy (increase just in size of cells)? - Hyperplasia is correct terem (incraes ein number ofc ells)
Urethra and Prostate
Urethra goes through the middle of the prostate
When gets bigger, urethra is compressed and ineterefers with ability to urinate
Define BPH
BPH is a histologic condition of proliferation of smooth muscle and epithelial cells in prostatic transition zone, which most commonly affects older adults ≥ 40 years old. Bothersome lower urinary tract symptoms associated with BPH include voiding symptoms, storage symptoms, and postmicturition dribbling.
Pathophsy BPH
BPH occurs when the enlarged prostate starts to push against the urethra, restricting the flow of urine. The bladder wall then begins to thicken and become irritable. The bladder starts to contract even when it contains only small amounts of urine. Over time, the bladder weakens and loses its ability to empty itself completely, leaving urine behind.
Normal Volume of the bBladder
Normal Volume of Bladder: 500 mL
When muscle is irritated, can start to give urge to urinate when not at 500 mL capacity
Pathogenesis of BPH
Cause of BPH
BPH Sx
Sx Vary
Occur gradually and can change overtime
Nocturia – 33% of daily urine output occurring at nightime
Complications of BPH
Acute, painful urinary retention, which can lead to acute renal failure.
Persistent or intermittent gross hematuria when tissue growth exceeds its blood supply.
Overflow urinary incontinence or unstable bladder.
Recurrent urinary tract infection that results from urinary stasis.
Bladder diverticula.
Bladder stones.
Chronic renal failure from long-standing bladder outlet obstruction.
↓ QOL (i.e. the reason we treat)
What is non-rx tx option that can be used for BPH?
Complications do not necessarily go away with tx – Why watchful waiting is an option
Usually tx sx to improve QOL
BPH Assements
International Prostate Symptom Score (IPSS) - questionnaire to determine between BPH or other incontinence and to assess severity
Scale of 0-35 (higher score = more severe symptoms)
Urinalysis – to rule out prostatitis, nephritis, UTI, etc. (Inflammation, infection)
Digital rectal exam (DRE) – to feel if smooth (likely benign) or nodular (maybe malignant) – Direct screenings if cancer is a concern
Prostate Specific Antigen (PSA) – baseline and for monitoring progression – it is a predictor for prostate SIZE (in combo with age) - no evidence to link to cancer
–> PSA – Traditional tool for cancer screening – Just size – Baseline to know where you start
Drugs that can exacerbate BPH
Should also evaluate medication list to see if any meds contributing
PPI’s preferred over ranitidine (anticholinergic)
Non Pharm RX BPH
RX Options BPH
Alpha-1 BLockers
alfuzosin, doxazosin, prazosin, silodosin, tamsulosin*, terazosin
a1 blockers MOA
Block norepinephrine at α1-receptors in the prostate gland, bladder neck and urethra (i.e.sphincter)
Addresses the dynamic component of obstruction, which can improve flow rates
*Alfuzosin, silodosin, and tamsulosin are “uro-selective”, others not
a1 EFfiocacy and effect noticed when
All equally effective at improving symptoms
Do NOT change size of prostate do NOT ↓ PSA
Works in 1-2 weeks (improve, not eliminate symptoms)(Some improvement in a few days) – Not a cure, but some improvement
Effecst of a-1 blockers and dosing
Effects are dose-related (including side effects)
All once-daily except prazosin (BID-TID)
Special Pop: a1 blockers in females? Renal Imapirment?
Tamsulosin – Help pass kidney stone – Female for hsort period of time – Likely kidney stone
Silodosin – Only one with dose adjustment for renal function
Adverse FEfects a-1 blockers
Blood pressure related – More common with non-selective than uro-selective - Doxazosin and prazosin dose escalation to reduce side effects
Some say to take with food – Take with food to reduce bioavilability to reduce hypotension – Just look it up in practice
A1 blockers CI and drug interactions
5-a reducatse inhibitos
Dutasteride (Avodart®) and finasteride (Proscar®)
5-a reductasse inhibitors MOA
Block conversion of intra-prostatic testosterone DHT
Site-specific reduction of static component of obstruction
To improve obstructive symptoms due to prostate size
5-a reductase inhibitors efficcay and benrfit
↓ prostate volume by 20-30% CAN ↓ PSA by 50%
Take a few months to work – up to 12 months for maximal effect
May slow progression or need for surgery (Since prostate ize reduced)
5-a reductas einhibitor dosing
reduced)
Both are once daily & no titration is required – One standard dose
Differenec of 5-a reductase to alpha-1 blockers? Adequate trial? Differences between 5-a reductase inhibs?
Actually work buy reducing size of prostate
Hormone meds – Take longer to work than alpha blcokers
Adequate trial: 6-12 months prior to move on to something else
Dutasteride – Type 1 and 2 5a-reductase (faster), finasteride (just type 2)
5-a reductase inhibs adverse efefcts and caution
risk of 5-a reductase inhibitors
PDE5 Inhibitors in BPH MOA
Primarily for erectile dysfunction (inhibits cGMP breakdown in smooth muscle of prostate & bladder as well as the corpus cavernosum, allowing chambers to fill and cause erection)
For BPH?? Exact mechanism unknown, but smooth muscle relaxation in and around prostate may provide relief
The vascular relaxation results in increased blood perfusion and may reduce BPH symptoms
PDE-5 Inhibitor in BPH: WAll or certain onmes? Use?
Tadalafiul or Cialis – Only one with indication – OD 5 mg dose – Likely absed on PK – Longer t1/2 – Chronic disease compared to PRN doses
PDE5-i Efficcay BPH. Adverse EFfects?
Tadalafil is the only PDE5i indicated for BPH – daily use, not PRN
5 mg daily did result in ↓ IPSS; combo product with finasteride available
Younger patients see best improvement
Takes ~4 weeks to see improvement
Adverse Effects
Headache, dyspepsia, lower back pain, hypotension*
*CAUTION WITH AN α1-BLOCKER (same contraindications as when used for erectile dysfunction)
Erections require stimulation and do not happen randomly
BPH + urge Incontinece
Combo Options for BPH. Guidelines?
Genrally start with 1
Alpha Blockers – Fastest results
Ad don 5-a if needed
Start both right away – if significant prostate enlargement – Takes awhile – Start alpha blocker to hep with sx improvement sooner
Natural Health products BPH
Pygeum – may ↓ nocturia and ↑ flow
Beta-sitosterol – no effect on prostate size but can improve urinary symptoms
Saw Palmetto - shows anti-DHT and anti-proliferative in vitro, but not clinically
not likely effective, but also not harmful
Outcomes of BPH Tx
