BPH

Question 1

What is BPH?

Answer 1

Enlarged prostate in the absence of malignancy

Can impede passage of urine leaving the bladder
-Growth of prostatic glandular tissue into lumen of urinary tract

-Increased smooth muscle tone of prostatic stroma and at bladder neck

Question 2

lower urinary tract sxs (LUTS) of BPH?

Answer 2

Weak urinary stream

Urinary hesitancy

Stream intermittency

Post void dribbling

Nocturia

AUA (American Urological Association) Symptom Score

Question 3

How do pts with BPH present?

Answer 3

Urinary retention

Recurrent urinary tract infections

Hx of cystolithiasis, other urolithiasis

Question 4

PE for BPH?

Answer 4

GU exam, DRE

Question 5

What labs should you check for BPH?

Answer 5

UA

PSA

Question 6

What urologic tests can you check for BPH?

Answer 6

Uroflow study—low flow rate

Post void residual – high residual

Cystoscopy—trabeculation, obstructive prostate encroaching into urinary outlet lumen, “kissing lobes”

Urodynamic study (UDS) may be indicated—low flow, elevated intravesical pressures

Question 7

Elevated intravesical pressure puts… at risk

Answer 7

the kidneys

Question 8

Tx options for BPH?

Answer 8

Watchful waiting
Lifestyle modification
Medication
Surgery

Question 9

What are some possible lifestyle modifications for BPH?

Answer 9

avoid fluid intake and diuretics in PM

if leg edema, elevate legs in evening to mobilize and eliminate fluid

Avoid drinks/food that exacerbate sx (caffeine, EtOH, acidic or spicy foods)

double void

avoid pseudoephedrine/ alpha agonists

Caution with anticholinergics: can cause retention

Question 10

What meds can be used to tx BPH?

Answer 10

Phytotherapy: plant therapy

Alpha-blockers

5-alpha-reductase inhibitors (5-ARI)

Question 11

MOA of alpha blockers?

Answer 11

Block stimulation of alpha-1 receptors of prostatic stroma and bladder neck

> relaxation of smooth muscle that restricts the flow of urine

> Relaxation allows for freer passage of urine

Question 12

Examples of Alpha 1 blockers?

Answer 12

Terazosin 1-10 mg

Doxazosin 1-8 mg

Question 13

Examples of Alpha 1-A blockers?

Answer 13

Tamsulosin 0.4-0.8 mg
Alfuzosin 10 mg
Silodosin 4-8 mg

Question 14

Alpha 1 blockers v. Alpha 1-A blockers?

Answer 14

Alpha-1-A blockers are more specific in targeting the urinary effects, while avoiding effects on blood pressure and nasal passages

Question 15

ADEs of Alpha Blockers?

Answer 15

Dizziness

Asthenia

Nasal congestion

Orthostatic
hypotension/syncope (rare)

Retrograde ejaculation

Intra-operative floppy iris syndrome (IFIS)- don’t start if cataract surg coming up

Question 16

MOA of 5 alpha reductase inhibitors?

Answer 16

Block conversion of testosterone to DHT

Lower DHT levels

Decrease prostatic glandular volume

Increase max urinary flow rates

Improve AUA sx scores

Decrease risk of BPH progression

Question 17

How long should a pt be on 5- alpha reductase inhibitors to see effect?

Answer 17

6 months

Question 18

What change in a pt labs will you see in pt taking a 5-alpha reductase inhibitor?

Answer 18

decreased in PSA by 50%

Question 19

Who are 5 alpha reductase inhibitors most effective in?

Answer 19

in larger volume prostates >40 cc and PSAs greater than 1.4

Question 20

Examples of 5 alpha reductase inhibitors?

Answer 20

Finasteride 5 mg po daily

Dutasteride 0.5 mg po daily

Question 21

ADEs of 5 alpha reductase inhibitors?

Answer 21

Impotence

Decreased libido

Lower ejaculatory volume

Gynecomastia

Question 22

What can you give to a pt who has BPH and ED?

Answer 22

Tadalafil (Cialis)

Question 23

Surgical options for BPH?

Answer 23

Transurethral Microwave Thermotherapy (TUMT)

Transurethral Incision of Prostate (TUIP)

Urolift ®

Transurethral Resection of Prostate (TURP)

Photoselective Vaporization of Prostate (PVP)

Open simple prostatectomy

Holmium Laser Enucleation of Prostate (HoLEP)

Question 24

Describe Transurethral Microwave Thermotherapy (TUMT)

Answer 24

Microwave device heats prostate and causes necrosis

Minimally invasive, outpatient, awake

Prostatic tissue sloughs and passes per urethra when patient voids

Question 25

Describe Transurethral Incision of Prostate (TUIP)

Answer 25

Cystoscopic incision made at 5 o’clock and 7 o’clock of the prostatic urethra, from bladder neck to just superior to verumontanum Smaller collar-type prostate Prostate springs open, no tissue is removed Less chance of retrograde ejaculation

Question 26

Describe Urolift surgery

Answer 26

Permanent implant into prostate Suture connected by 2 anchoring devices Permanent suture between the anchors compresses prostatic tissue, widening urethral lumen

Question 27

Describe Transurethral Resection of Prostate (TURP)

Answer 27

Transurethral resectoscope Under direct visualization, electrocautery energy scoops out “chips” of prostatic tissue Chips go into bladder, are evacuated out and sent to pathology

Question 28

What surgery is considered the gold standard for BPH?

Answer 28

TURP

Question 29

Side effects of TURP?

Answer 29

Retrograde ejaculation TUR Syndrome Hematuria

Question 30

What sxs are included in TUR syndrome?

Answer 30

Hyponatremia Mental confusion Hypertension Visual changes

Question 31

How can you tx hematuria secondary to TURP?

Answer 31

Continuous bladder irrigation (CBI/CVI) Transfusion

Question 32

When might you perform Photoselective Vaporization of Prostate (PVP)?

Answer 32

if pt is anticoagulanted

Question 33

Describe open simple prostatectomy?

Answer 33

Open suprapubic midline incision Prostatic capsule incised Glandular adenoma is enucleated Prostatic capsule closed Postop catheter and CBI

Question 34

When might you perform an open simple prostectomy?

Answer 34

for very large prostates >80 cc

Question 35

Indication for Holmium Laser Enucleation of Prostate (HoLEP)? How is this done

Answer 35

for very large prostates done transurethrally