BPH Flashcards by Nayla Mansoor

What is Benign Prostatic Hyperplasia

MC benign neoplasm of american men

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What are Obstructive signs and symptoms of BPH

Urinary hesitancy
Dribbling
Bladder fullness post voiding

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What are Irritative signs and symptoms of BPH

Urinary frequency
Urgency
Nocturia
(longstanding obstruction at bladder neck)

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What are complications of BPH

CKD
hematuria
incontinence
recurrent UTI 
bladder diverticula 
bladder stones

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In which lobe is cancer most common

posterior lobe of prostate

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

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

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What are Testosterone and Androstenedione and what are they responsible for

-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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What is DHT

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

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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How do we improve urine flow in men with BPH

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

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What are the normal and abnormal prostate gland tissue ratios

Normal= Stromal:Epithelial is 2:1 
Abn= Stromal:Epithelial is 5:1

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What are the two general Tx for BPH

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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What are Static factors of BPH

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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What are Dynamic factors of BPH

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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How does micturition occur

PNS causes detrusor contraction and internal urethral sphincter relaxation

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What meds can exacerbate BH symptoms

Anticholinergics 
Antihistamines 
TCA
Phenothiazines 
(dc med usually relieves Sx)

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

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

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

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Reduce static factor: interfere w/ testosterone stimulating prostate enlargement
Reduce dynamic factor: relax smooth muscle
Improve urine storage capacity: relax detrusor

Why is BPH MC in 60+ y/o

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2/2 androgen driven growth in size of prostate

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

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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)

What is significant about Terazosin and Doxazosin

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They are second gen, and immediate release

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

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

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

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

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

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

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

What meds relax the detrusor muscle of bladder

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

What relieves voiding Sx

alpha 1 antagonist (voiding sx are dynamic)

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

5 alpha reductase blocker (no DHT= less enlargement)

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

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

What is Alfuzosin

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

How long do 5a reductase inhibitors take to work

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

What are the ADE of 5a reductase inhibitors

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

What are the ADE of Alpha 1 Antagonists

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

What must you monitor if taking alpha 1 blockers

BP | HR

How do you administer alpha 1 blockers

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

Important info to tell patient (pt education)

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

What must you monitor if taking 5a reductase inhibitors

PSA | -If adherent, patients PSA should decrease by 50%

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

a1 blocker: 1-6 weeks peak onset | 5a: 3-6 months peak onset

What are ADE of PDE inhibitors

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

What must you monitor when taking PDE inhibitors

BP Pulse hearing loss

What must you monitor if on anticholinergics

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

How does Mirabegron work

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

What are ADE of Mirabegron

``` *HTN tachy constipation diarrhea HA *Impaired cognition -ADE are dose dependent and reversible ```

What must you monitor if taking Mirabegron

BP | bowel habits

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

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

BPH Flashcards

(44 cards)