BPH

Question 1

Tissue Types in Prostate

Answer 1

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

Question 2

Functions of the Prostate

Answer 2

To contribute fluid to ejaculate
To constrict urethra during ejaculation to avoid contamination with urine

Question 3

What is BPH?

Answer 3

Hyperthrophy (increase just in size of cells)? - Hyperplasia is correct terem (incraes ein number ofc ells)

Question 4

Urethra and Prostate

Answer 4

Urethra goes through the middle of the prostate
When gets bigger, urethra is compressed and ineterefers with ability to urinate

Question 5

Define BPH

Answer 5

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.

Question 6

Pathophsy BPH

Answer 6

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.

Question 7

Normal Volume of the bBladder

Answer 7

Normal Volume of Bladder: 500 mL
When muscle is irritated, can start to give urge to urinate when not at 500 mL capacity

Question 8

Pathogenesis of BPH

Answer 8

Question 9

Cause of BPH

Answer 9

Question 10

BPH Sx

Answer 10

Sx Vary
Occur gradually and can change overtime
Nocturia – 33% of daily urine output occurring at nightime

Question 11

Complications of BPH

Answer 11

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)

Question 12

What is non-rx tx option that can be used for BPH?

Answer 12

Complications do not necessarily go away with tx – Why watchful waiting is an option
Usually tx sx to improve QOL

Question 13

BPH Assements

Answer 13

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

Question 14

Drugs that can exacerbate BPH

Answer 14

Should also evaluate medication list to see if any meds contributing
PPI’s preferred over ranitidine (anticholinergic)

Question 15

Non Pharm RX BPH

Answer 15

Question 16

RX Options BPH

Answer 16

Question 17

Alpha-1 BLockers

Answer 17

alfuzosin, doxazosin, prazosin, silodosin, tamsulosin*, terazosin

Question 18

a1 blockers MOA

Answer 18

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

Question 19

a1 EFfiocacy and effect noticed when

Answer 19

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

Question 20

Effecst of a-1 blockers and dosing

Answer 20

Effects are dose-related (including side effects)
All once-daily except prazosin (BID-TID)

Question 21

Special Pop: a1 blockers in females? Renal Imapirment?

Answer 21

Tamsulosin – Help pass kidney stone – Female for hsort period of time – Likely kidney stone
Silodosin – Only one with dose adjustment for renal function

Question 22

Adverse FEfects a-1 blockers

Answer 22

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

Question 23

A1 blockers CI and drug interactions

Answer 23

Question 24

5-a reducatse inhibitos

Answer 24

Dutasteride (Avodart®) and finasteride (Proscar®)

Question 25

5-a reductasse inhibitors MOA

Answer 25

Block conversion of intra-prostatic testosterone  DHT Site-specific reduction of static component of obstruction To improve obstructive symptoms due to prostate size

Question 26

5-a reductase inhibitors efficcay and benrfit

Answer 26

↓ 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)

Question 27

5-a reductas einhibitor dosing

Answer 27

reduced) Both are once daily & no titration is required – One standard dose

Question 28

Differenec of 5-a reductase to alpha-1 blockers? Adequate trial? Differences between 5-a reductase inhibs?

Answer 28

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)

Question 29

5-a reductase inhibs adverse efefcts and caution

Answer 29

Question 30

risk of 5-a reductase inhibitors

Answer 30

Question 31

PDE5 Inhibitors in BPH MOA

Answer 31

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

Question 32

PDE-5 Inhibitor in BPH: WAll or certain onmes? Use?

Answer 32

Tadalafiul or Cialis – Only one with indication – OD 5 mg dose – Likely absed on PK – Longer t1/2 – Chronic disease compared to PRN doses

Question 33

PDE5-i Efficcay BPH. Adverse EFfects?

Answer 33

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

Question 34

BPH + urge Incontinece

Answer 34

Question 35

Combo Options for BPH. Guidelines?

Answer 35

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

Question 36

Natural Health products BPH

Answer 36

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

Question 37

Outcomes of BPH Tx

Answer 37