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Summer Pharm Exam 1 > BPH > Flashcards

BPH Flashcards

1
Q

What is Benign Prostatic Hyperplasia

A

MC benign neoplasm of american men

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2
Q

What are Obstructive signs and symptoms of BPH

A

Urinary hesitancy
Dribbling
Bladder fullness post voiding

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3
Q

What are Irritative signs and symptoms of BPH

A

Urinary frequency
Urgency
Nocturia
(longstanding obstruction at bladder neck)

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4
Q

What are complications of BPH

A 
CKD
hematuria
incontinence
recurrent UTI 
bladder diverticula 
bladder stones
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5
Q

In which lobe is cancer most common

A

posterior lobe of prostate

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6
Q

What are the 3 types of tissue of the prostate and what do they do

A
  1. Epithelial (glandular)- makes secretions; stimulated by androgens (DHT) to grow
  2. Stromal (smooth muscle)- has alpha 1 receptors; NE causes contraction (= extrinsic urethra compression= decreased bladder emptying)
  3. Capsule (fibrous CT and smooth muscle)- has alpha1 receptors; NE causes contraction
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7
Q

What are Testosterone and Androstenedione and what are they responsible for

A

-Inactive forms converted to DHT (active) by 5a reductase in target cells
penile/scrotal enlargement
increased muscle mass
normal male libido

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8
Q

What is DHT

A

Active metabolite that has greater affinity for, and forms a more stable complex with intraprostatic androgen receptors
-In prostate, DHT causes growth of gland

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9
Q

What are the two types of 5a reductase (converts testosterone to DHT)

A

Type 1: local to sebaceous glands in frontal scalp, liver, skin= acne, increased body and facial hair
Type 2: local to prostate, genital, and hair follicles of scalp= more DHT= growth of prostate gland

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10
Q

How do we improve urine flow in men with BPH

A

Reverse the smooth muscle contraction in enlarged prostate (caused by NE in stromal and capsule)

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11
Q

What are the normal and abnormal prostate gland tissue ratios

A 
Normal= Stromal:Epithelial is 2:1 
Abn= Stromal:Epithelial is 5:1
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12
Q

What are the two general Tx for BPH

A

5a reductase inhibitors= less DHT= reduce enlarged prostate (by 25%)
Alpha antagonist= Sx management of urinary flow (relax smooth muscle so more urine can pass)

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13
Q

What are Static factors of BPH

A

Enlargement of prostate= physical block at bladder neck= urine obstruction

  • Due to 5a reductase converting to DHT in epithelial tissue
  • Sx are exacerbated by stress or pain
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14
Q

What are Dynamic factors of BPH

A

Contraction of prostate around urethra

  • Due to excess alpha 1 tone of stromal tissue
  • *Sx of dynamic factors are obstructive voiding (with normal size prostate)
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15
Q

How does micturition occur

A

PNS causes detrusor contraction and internal urethral sphincter relaxation

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16
Q

What meds can exacerbate BH symptoms

A 
Anticholinergics 
Antihistamines 
TCA
Phenothiazines 
(dc med usually relieves Sx)
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17
Q

How do you Tx mild ASx or mildle bothersome BPH (if without complications)

A

Watchful waiting
Behavior modification
Follow up q12 mo to assess worsening S/Sx

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18
Q

What are the 3 categories of BPH drug therapy (mod-severe Sx)

A
  1. Reduce static factor: interfere w/ testosterone stimulating prostate enlargement
  2. Reduce dynamic factor: relax smooth muscle
  3. Improve urine storage capacity: relax detrusor
19
Q

Why is BPH MC in 60+ y/o

A

2/2 androgen driven growth in size of prostate

20
Q

What reduces dynamic (contraction of stromal tissue) factors of BPH

A
  • nonselective alpha 1 blocker: Prazosin, Alfuzosin (er), Terazosin (ir), Doxazosin* (ir)
  • selective alpha 1 blocker: Tamsulosin* aka flomax, Silodosin
  • Smooth muscle relaxation: Tadalafil aka cialis (PDE11 inhibitor)
21
Q

What is significant about Terazosin and Doxazosin

A

They are second gen, and immediate release

Must slow titrate up to minimize orthostatic hypotension and first-dose syncope

22
Q

What is the Slow titration (schedule 1) for Terazosin and Doxazosin administration

A

Day 1-3: 1mg at bedtime
Day 4-14: 2mg
Week 2-6: 5mg
Week 7+: 10mg (bedtime)

23
Q

What is Quick titration (schedule 2) for Terazosin and Doxazosin

A

Day 1-3: 1mg at bedtime
Day 4-14: 2mg
Week 2-3: 5mg
Week 4+: 10mg at bedtime

24
Q

What meds reduce static (enlargement 2/2 5a reductase) factor

A
  • 5a reductase blocker: Finasteride*, Dutasteride
  • DHT receptor blocker: Bicalutamide, Flutamide
  • Pituitary blocker (no LH): Leuprolide, Goserelin
  • Pituitary blocker and androgen receptor blocker: Megestrol acetate
25
Q

What meds relax the detrusor muscle of bladder

A

Oxybutynin* (ditropan)
Tadalafil (Cialis)- PDE11 inhibitor
Mirabegron- B3 agonist

26
Q

What relieves voiding Sx

A

alpha 1 antagonist (voiding sx are dynamic)

27
Q

What should patients with a prostate of at least 40g (norm 20) take

A

5 alpha reductase blocker (no DHT= less enlargement)

28
Q

What are the ADE of Second generation (IR) alpha 1 antagonists

A

cardiovascular effects;
first dose syncope, orthostatic hypotension, dizziness
*Use third gen (Tamulosin, Silodosin) as alternatives, they are uroselective

29
Q

What is Alfuzosin

A

an extended release second gen that functions as uroselective
Less cardiac effects than Terazosin and Doxazosin

30
Q

How long do 5a reductase inhibitors take to work

A

Up to 6 months! Takes a while to shrink the prostate

31
Q

What are the ADE of 5a reductase inhibitors

A 
Decreased libido 
ED 
Ejaculaiton disorders 
*Gynecomastia
(No 5a reductase= no DHT)
32
Q

What are the ADE of Alpha 1 Antagonists

A 
**Floppy iris syndrome
Syncope
light headed 
orthostatic hypotension
tachy (cardiac adverse effects) 
nasal congestion 
Ejaculatory dysfunction 
priapism
33
Q

What must you monitor if taking alpha 1 blockers

A

BP

HR

34
Q

How do you administer alpha 1 blockers

A

start on lowest possible dose
take first dose at bedtime
slowly titrate up

35
Q

Important info to tell patient (pt education)

A

If you have had cataract surgery, inform ophthalmologist ASAP to prevent complications
If you have a painful erection lasting longer than 4 hours, seek immediate medical attention

36
Q

What must you monitor if taking 5a reductase inhibitors

A

PSA

-If adherent, patients PSA should decrease by 50%

37
Q

What is the difference in onset time between 5a reductase inhibitors and alpha 1 blockers

A

a1 blocker: 1-6 weeks peak onset

5a: 3-6 months peak onset

38
Q

What are ADE of PDE inhibitors

A

HA, dizziness, congestion, dyspepsia, back pain, myalgia, hearing loss
***If hearing loss occurs, DC Tadalafil

39
Q

What must you monitor when taking PDE inhibitors

A

BP
Pulse
hearing loss

40
Q

What must you monitor if on anticholinergics

A

mental status
bowel habits
ability to urinate
-ADE are dose dependent and reversible

41
Q

How does Mirabegron work

A

B3 receptors are in the bladder- when stimulated, increase cAMP and relax detrusor muscle relieving irritative Sx and increasing capacity
B3 agonist= relaxes detrusor muscle in bladder
Usually onset in 2 weeks, sometime 8
Does have some cardiovascular effects

42
Q

What are ADE of Mirabegron

A 
*HTN
tachy
constipation
diarrhea
HA
*Impaired cognition 
-ADE are dose dependent and reversible
43
Q

What must you monitor if taking Mirabegron

A

BP

bowel habits

44
Q

What are your surgical options for BPH if with mod-severe Sx and patient does not respond/tolerate drug therapy

A 
TURP (do biopsy) 
Green light (cant do biopsy)

Summer Pharm Exam 1 (8 decks)

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