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BPH Flashcards

1
Q

What are the functions of the prostate? (2)

A
  1. To contribute fluid to ejaculate
  2. To constrict urethra during ejaculation to avoid contamination with urine
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2
Q

What are the 3 tissue types the prostate consists of?

A
  1. Epithelia tissue (aka - glandular tissue)
    - Responsive to testosterone
  2. Stromal tissue (aka - smooth muscle)
    - Rich with alpha1-receptors
  3. The capsule (outer shell)
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3
Q

The prostate is close in proximity to the bladder with __________ receptors

A

muscarinic

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4
Q

What is BPH?

A

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

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5
Q

Explain how BPH occurs/the pathophysiology

A

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.

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6
Q

What factor is most likely responsible for prostate enlargement?

A

Androgens
- Likely due to increased activity of intra-prostatic 5-alpha-reductase despite overall declining androgens with age.

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7
Q

What factor is most likely responsible for detrusor muscle decline?

A

Age

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8
Q

BPH is caused by a combination of __________ + _____

A

androgens (DHT); age (detrusor muscle)

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9
Q

What are the 3 main groups of symptoms of BPH?

A
  1. Storage
  2. Voiding
  3. Post-micturition
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10
Q

What are the ‘storage’ symptoms of BPH? (4)

A
  1. Frequency
  2. Nocturia
  3. Urgency (time between signal and leakage)
  4. Terminal dribbling
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11
Q

What are the ‘voiding’ symptoms of BPH? (5)

A
  1. Obstructive - weak or interrupted stream
  2. Difficulty initiating
  3. Straining
  4. Intermittency
  5. Pain while peeing
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12
Q

What are the ‘post-micturition’ symptoms of BPH? (2)

A
  1. Post-void dribbling
  2. Sensation of incomplete bladder emptying
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13
Q

What are the complications of BPH? (8)

A
  1. Decreased QOL (i.e., the whole reason we treat)
  2. Acute, painful urinary retention, which can lead to acute renal failure.
  3. Persistent or intermittent gross hematuria when tissue growth exceeds its blood supply.
  4. Overflow urinary incontinence or unstable bladder.
  5. Recurrent urinary tract infection that results from urinary stasis.
  6. Bladder diverticula.
  7. Bladder stones.
  8. Chronic renal failure from long-standing bladder outlet obstruction
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14
Q

What are the 4 ways to assess for BPH?

A
  1. International Prostate Symptom Score (IPSS)
  2. Urinalysis
  3. Digital rectal exam (DRE)
  4. Prostate Specific Antigen (PSA)
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15
Q

Describe the International Prostate Symptom Score (IPSS)

A

A questionnaire to determine between BPH or other incontinence and to assess severity
(Scale of 0-35 [higher score = more severe symptoms])

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16
Q

Why do a urinalysis for BPH assessment?

A

To rule out prostatitis, nephritis, UTI, etc.

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17
Q

Why do digital rectal exam during BPH assessment?

A

To feel if [the prostate is] smooth (likely benign) or nodular (maybe malignant)

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18
Q

Describe the purpose of prostate specific antigen (PSA) for BPH assessment

A

Baseline and for monitoring progression - it is a predictor for prostate SIZE (in combo with age) - no evidence to link to cancer

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19
Q

What are some drugs that can exacerbate BPH? (3+4)

A
  1. Androgens - encourage growth
  2. Anticholinergics - cause urinary retention
    - Antidepressants - TCAs
    - Antihistamines
    - Antipyschotics - 1st generation
    - Muscle relaxants
  3. Stimulants - stimulate sphincter muscle and worsen symptoms
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20
Q

What are some non-pharm options to try for BPH? (10)

A
  1. Limit fluid intake in evening
  2. Limit caffeine and alcohol use
  3. Limit diuretic use
  4. Limit anticholinergic use
  5. Smoking cessation (weak correlation)
  6. Bladder training
  7. Pelvic floor exercises
  8. Stay physically active
  9. Avoid/treat constipation
  10. Watchful waiting
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21
Q

What are the 4 groups of pharmacological options for BPH treatment?

A
  1. Alpha1-blockers
  2. 5-alpha-reductase inhibitors
  3. PDE5Is
  4. Anticholinergics*?
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22
Q

List the alpha1-blocker drugs used for BPH treatment (6)

A
  1. Alfuzosin*
  2. Doxazosin
  3. Prazosin
  4. Silodosin*
  5. Tamsulosin*
  6. Terazosin
    * = uro-selective
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23
Q

Name the 2 5-alpha-reductase inhibitor meds for BPH treatment

A
  1. Finasteride
  2. Dutasteride
24
Q

What is the PDE5I med used for BPH treatment?

A

Tadalafil

25
Q

What is the MOA of alpha1-blocker medications for BPH treatment?

A

Block norepinephrine at alpha1-receptors in the prostate gland, bladder neck and urethra (i.e., sphincter)
- Addresses the dynamic component of obstruction, which can improve flow rate

26
Q

How does efficacy differ between the alpha1-blocker medications for BPH?

A

They don’t - all equally effective at improving symptoms

27
Q

Alpha1-blocker medications do NOT do what?

A

Do NOT change size of prostate –> do NOT decrease PSA

28
Q

How quick do alpha1-blocker meds work?

A

1-2 weeks (improve, not eliminate symptoms)

29
Q

Effects of alpha1-blockers are ____-_______ (including side effects)

A

dose-related

30
Q

How are alpha1-blockers dosed (how many times per day)?

A

All once-daily except prazosin

31
Q

What are the adverse effects of alpha1-blockers? (7)

A
  1. Dizziness
    - First-dose syncope, orthostatic hypotension
  2. Fatigue
  3. Rhinitis
  4. Headaches
  5. Decreased volume of ejaculate
  6. Retrograde ejaculation
  7. Intraoperative floppy iris syndrome (IFIS) - relaxes dilator muscle in pupil (Most cases with tamsulosin + cataract surgery)
32
Q

What are the contraindications/drug interactions to be aware of in alpha1-blockers? (4)

A

1, Anyone at risk for hypotension (additive effects) –> falls are potentially life-changing events
2. Caution in heart failure due to hypotension
3. 3A4 inhibitors/inducers (alfuzosin, silodosin, tamsulosin are metabolized by 3A4) or liver dysfunction
- Silodosin also affected by P-glycoprotein and UGT2B7 inhibitors/inducers
4. Dosage adjustment for renal impairment
(Need to consider if correct drug for the symptoms reported)

33
Q

What is the MOA of 5-A-reductase inhibitors?

A

Block conversion of intra-prostatic testosterone –> DHT
- Site-specific reduction of static component of obstruction

34
Q

What are 5-A-reductase inhibitors used for/what is the efficacy? (3)

A
  1. To improve obstructive symptoms due to prostate size
  2. Decrease prostate volume by 20-30% –> CAN decrease PSA by 50%
  3. May slow progression or need for surgery
35
Q

How quick for 5-A-reductase inhibitors to work for BPH?

A

Take a few months to work - up to 12 months for maximal effect

36
Q

How often are 5-A-reductase inhibitors dosed?

A

Both are once daily and no titration is required

37
Q

What are the adverse effects of 5-A-reductase inhibitors? (5)

A
  1. Ejaculatory dysfunction
  2. Loss of libido
  3. Impotence
    (1-3 can cause/is sexual dysfunction)
  4. Gynecomastia
  5. Plus any effects on mental health
38
Q

What is a unique side effect of 5-A-reductase inhibitors for women?

A

Pregnant/planning/child-bearing aged women DO NOT handle tablets
- Can cause birth defects in male fetus - where androgens present

39
Q

What is the bottom-line regarding 5-A-reductase inhibitors and cancer risk?

A

Not approved to prevent prostate cancer; for symptoms of BPH

40
Q

What is the MOA of PDE5Is specifically for BPH?

A

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

41
Q

How is tadalafil dosed for BPH?

A

Daily use, NOT PRN

42
Q

Who is more likely to see benefit from PDE5I for BPH?

A

Younger patients see best improvement

43
Q

How quick do PDE5Is work for BPH?

A

Takes ~4 weeks to see improvement

44
Q

What are the ADEs of PDE5Is? (4)

A
  1. Headache
  2. Dyspepsia
  3. Lower back pain
  4. Hypotension*
    * = caution with an alpha1-blocker (same contraindication as when used for ED)
    (Erections require stimulation and do not happen randomly)
45
Q

BPH is often concurrent with what co-morbidity?

A

Urge incontinence

46
Q

When might anticholinergics be given for BPH. How?

A
  • Carefully if overactive bladder (i.e., urgency, frequency, etc.)
  • Start low, go slow, monitor, discontinue if no response or worsening
47
Q

What are some examples of anticholinergics used for BPH/incontinence? (5)

A
  1. Fesoterodine
  2. Darifenacin
  3. Oxybutynin
  4. Solifenacin
  5. Talterodine
48
Q

How quick for anticholinergics to work in BPH/incontinence?

A

Works in 1 week to 1 month

49
Q

What is the only combo product available in Canada for BPH?

A

Jalyn (dutasteride 0.5mg/tamsulosin 0.4mg)

50
Q

First-line treatment for BPH is?

A

Alpha1-blockers

51
Q

Combination products for BPH treatment mostly used if ________ ___________

A

prostate enlargement

52
Q

What are 3 natural health products that might be tried for BPH?

A
  1. Pygeum
    - May decrease nocturia and increase flow
  2. Beta-sitosterol - no effect on prostate size but can improve urinary symptoms
  3. Saw Palmetto - shows anti-DHT and anti-proliferative in vitro, but not clinically
    - Not likely effective, but also not harmful
53
Q

What are the best possible outcomes of BPH treatment? (6)

A
  1. Less frequency
  2. Less urgency
  3. Greater force of stream
  4. More complete emptying
  5. As little impact as possible for adverse effects
  6. Increased QoL
54
Q

When might BPH surgery be considered? (The ‘ifs’) (6)

A
  1. Failed trials of voiding (refractory or recurrent urinary retention)
  2. Renal insufficiency due to obstruction
  3. Failed pharmacotherapy (i.e., not effective)
  4. Desire to stop meds
  5. Prohibitive costs to meds
  6. Recurrent hematuria, UTIs, or bladder stones
55
Q

What are the 3 BPH surgery options?

A
  1. Surgery - prostate vaporization, transuretheral resection of the prostate (TURP)
  2. Brachytherapy, hormone therapy, prostatecetomy if cancer
  3. Catheterization if not a candidate for any other intervention

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