BPH

Question 1

BPH

Answer 1

• Increase in the # of prostatic stromal and epithelial cells that commonly contribute to lower urinary tract symptoms (LUTS) in aging men
• Larger prostate does not mean more LUTS
• BPH is a physiologic hyperplasia

*there is not an increased risk of prostate cancer in the pt.

Question 2

LUTS

Answer 2

• Lower Urinary Tract Symptoms
• A constellation of symptoms that include poor stream, intermittent stream or hesitancy, terminal dribbling, straining, urgency, nocturia, and sensation of incomplete bladder emptying

Question 3

BPH epidemiology

Answer 3

• Generally ~70% of men ages 60-69 and 80% of men >70 are affected by BPH

Question 4

Blood supply to the prostate

Answer 4

• Inferior vesicle artery

Question 5

Autonomic innervation of the prostate

Answer 5

• Cavernous nerve; facilitates seminal emission

Question 6

Zone of prostate where cancer usually starts

Answer 6

• Peripheral zone

Question 7

Function of prostate

Answer 7

• Male sex accessory gland
• It is roughly 20-30 gms in the adult male (~size of walnut)
• Its function is to secrete certain enzymes into the semen to facilitate sperm survival in the female reproductive tract

*prostatic secretions have a large conc. of Zinc compared to blood’s

• Also aids in emission of semen during ejaculation

*contracts around the urethra which assists in the propulsion of semen out of the body

Question 8

Prostatic growth

Answer 8

• The growth of the prostate is mainly regulated by androgens, most specifically thru DHT
• As the prostate grows, there is an increase in the amount of prostatic stroma and an increase in the # of alpha-1 receptors in the stroma as well

Question 9

Prostate alpha-1 receptors

Answer 9

• Mediate the contractions of smooth muscle
• Primarily located in the prostatic stroma and bladder neck and the main subtype found are alpha-1A receptors
• Their contraction leads to a restriction of urine flow

Question 10

Differentials for BPH symptoms

Answer 10

• BPH symptoms are related to urination
• UTI
• Bladder stones
• Neurogenic bladder
• Urethral stricture
• Bladder cancer
• Urethritis

Question 11

Medications that can exacerbate symptoms of bladder outlet obstruction

Answer 11

• Anticholinergics

*atropine, oxybutynin, dicycloamine, glycopyrrolate, etc

• Antihistamines

*diphenhydramine, hydroxyzine, chlorpheniramine, etc.

• Antidepressants

*TCA’s

• Sympathomimetics (alpha-adrenergic agonists)

*ephedrine, phenylephrine`

Question 12

Medications for urination problems

Answer 12

• Alpha-blockers
• 5alpha-reductase inhibitors
• Cialis

Question 13

Alpha blockers MOA

Answer 13

• Blocks alpha receptors causing relaxation of the smooth muscle

Question 14

Non-selective alpha-1 blockers for BPH

Answer 14

• Terazosin, doxazosin, alfuzosin
• May take up to 2-4wks for improvement of urination

Question 15

Selective alpha-1A blockers for BPH

Answer 15

• Tamsulosin, Silodosin
• Take up to 8hrs for improvement of urination

Question 16

Alpha blockers adverse effects

Answer 16

• Orthostatic hypotension, retrograde ejaculation, dizziness, asthenia, nasal congestion, syncope

Question 17

Intraoperative floppy iris syndrome (IFIS)

Answer 17

• A complication that could occur during cataract surgery that is assoc. w/ the use of alpha-blockers, but is most strongly assoc. w/ the use of Tamsulosin
• Opthalmologists should be aware of any pt. that has been treated w/ tamsulosin may be susceptible to this complication
• Discontinuing the medication prior to surgery will not reduce the risk of it occurring however. It is a permanent change

Question 18

5alpha-reductase inhibitors MOA

Answer 18

• Inhibits 5alpha-reductase thereby lowering the conc. of DHT

Question 19

5alpha-reductase inhibitors for BPH

Answer 19

• Finasteride; inhibits type 2
• Dutasteride; inhibits type 1 and 2

Question 20

5alpha-reductase inhibitors clincal effects

Answer 20

• Indicated in men w/ larger prostates
• Reduces prostate volume by up to 25-50%
• Increases max urinary flow rate
• May take up to 3-6 months for maximal effect
• Decreases total PSA by ~50% after 3-6 months of use

Question 21

5alpha-reductase inhibitors adverse effects

Answer 21

• Impotence
• Decreased libido
• Decreased volume of ejaculate
• Gynecomastia

Question 22

BPH combination therapy

Answer 22

• CombAT trial and MTOPS trial showed…
• Combination therapy b/w an alpha blocker and 5alpha-reductase inhibitor have been shown to decrease AUA symptom score and decrease risk of clinical progression of BPH

Question 23

Cialis

Answer 23

• Type 5 Phosphodiesterase (PDE5) inhibitor
• Blocks the breakdown of cGMP and thereby enhances the effect of NO on vasodilation of the blood vessels in the prostate (as well as the corpus cavernosum)
• Originally marketed to treat men w/ erectile dysfunction, recently received additonal indication to treat BPH as well

Question 24

Cialis adverse effects

Answer 24

• Headache, flushing, nasal congestion, blurry vision, priapism
• Contraindicated in pts who are also taking nitrates or nitric oxides
• Hypotension may also occur in men taking an alpha blocker

Question 25

Anticholinergics MOA

Answer 25

- Non-selectively inhibits the cholinergic muscarinic receptors in the bladder to allow for detrusor and therefore bladder relaxation

Question 26

Anticholinergic drugs for BPH

Answer 26

- Oxybutynin, darifenacin, solifenacin, tolterdrine, fesoterodrine, trospium - Indicated in men w/ irritative voiding symptoms w/ BPH who have adequate PVRs - Has been shown to improve BPH symptom scores, however, has mixed results on objective data such as PVR and Qmax

Question 27

Receptor responsible for detrusor function?

Answer 27

- M3 cholinergic receptor

Question 28

Most common receptor in the bladder?

Answer 28

- M2 cholinergic receptor

Question 29

Indications for bladder surgery

Answer 29

- Urinary retention - UTIs - Gross hematuria - Bladder or renal calculi stones - Renal insufficiency or hydronephrosis - Failed medical management`

Question 30

TURP

Answer 30

- Transurethral resection of the prostate - Gold standard of endoscopic management of BPH - Go in w/ a resectoscope and resect the adenomatous issue in the transition zone

Question 31

Laser TURP

Answer 31

- When compared to monopolar/bipolar TURP, reduced risk of intraoperative fluid absorption, bleeding, retrograde ejaculation, ED, and incontinence - 2 types used primarily in clincal practice currently \*Holmium:Yttrium Aluminum Garnet \*Potassium Titanyl Phosphate (KTP) laser aka Greenlight Laser

Question 32

Monopolar and Bipolar TURP

Answer 32

Monopolar - Irrigate w/ glycine during procedure \*increased risk of TUR (transurethral resection) syndrome \*dilution HYPOnatremia \*AMS/seizures Bipolar - Irrigate w/ normal saline during procedure \*no increased risk of TUR syndrome

Question 33

TUIP

Answer 33

- Incision from UO to verumontanum down to capsule - Less risk of retrograde ejaculation compared to TURP - Less risk post op complications - Good for smaller prostates (\<30gms)

Question 34

Simple prostatectomy

Answer 34

- Retropubic, suprapubic, perineal approaches - Typically for large prostates \>80gm - Contraindicated in pts w/ known prostate cancer