BPH Flashcards
What is BPH
enlarged prostate in absence of malignancy
Pathologically, how can BPH impede passage of urine leaving the bladder
- Glandular tissue grows into lumen of urinary tract
- Increased smooth muscle tone of prostatic stroma and at bladder neck
What are Sx of LUTS (lower urinary tract symptoms)
weak stream hesitancy stream intermittency post void dribbling nocturia
Other than LUTS, how will BPH usually present
Urinary retention
Recurrent UTI
Hx of cystolithiasis
What scoring systems can be used to evaluate BPH
AUA symptom score (0-35) for urinary Sx Bother index (0-6) for impact on QOL
What prostatic abnormalities should you look for on DRE for BPH
Indurated Firm Boggy Nodular \+/- tenderness
What urologic labs can we get to evaluate BPH
UA
Uroflow study (voided volume, peak flow in ml/sec, mean flow rate)- will be low
Post Void Residual- high residual
Cytoscopy- trabeculation, kissing lobes, prostate protruding into lumen
Urodynamic study- low flow, high intravesical pressure
How do you treat BPH (categories)
Watchful waiting (monitor Sx, recheck labs prn)
Lifestyle modification
Meds
Surgery
What lifestyle modifications can help treat BPH
Avoid fluid intake and diuretics in evening (nocturia) If leg edema, elevate LE at night to mobilize and eliminate fluid Avoid food/drinks that exacerbate Sx (caffeine, EtOH, acidic, spicy) Double void to completely empty bladder Avoid pseudoephedrine/alpha agonist Caution anticholinergiscs (cause retention)
What meds can be used to Tx BPH (categories)
Phytotherapy (Saw palmetto)
Alpha blockers
5 alpha reductase inhibitors
What is the MOA of Alpha blockers
Block alpha 1 receptors in the bladder and prostatic stroma= relax smooth muscle= free passage of urine
What are the alpha 1 blockers
Terazosin
Doxazosin
-Alpha 1A blockers are more specific to urine effects and dont affect BP and nasal passages: Tamsulosin (flomax), Silodosin, Alfuzosin
ADE of Alpha blockers include
*Dizziness
*Retrograde ejaculation
*Inoperative floppy iris syndrome
Orthostatic hypotension
asthenia, congestion
Who are alpha blockers CI in
patients about to have cataract surgery
What is the MOA of 5ARI
Block conversion of testosterone to DHT
Lower DHT levels= prostate gland shrinks= decreased risk of BPH progression
Improved AUA scores (less urinary Sx)
Most beneficial in prostate >40 g (norm 20), and PSA >1.4
Are 5ARI effects immediate
No, can take up to 6 months!
But you should see PSA decrease by about 50%
Possibly stops chronic hematuria 2/2 prostatic varicies
What are the 5ARI
Finasteride
Dutasteride
ADE of 5ARI include
Impotence Decreased libido low ejaculatory volume gynecomastia (low DHT!)
What is preferred med combo to treat BPH
Alpha blocker + 5ARI
(Tamulosin + Dutasteride)
a-blocker gives early response to appease patient, while 5ARI takes time to kick in
What is the only medication FDA approved for treating BPH
Radalafil (cialis), a PDE5 inhibitor (technically isoenzyme 11 per brubs)
What surgeries are available for BPH
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
Gold standard surgical treatment for BPH is
TURP!
Under visualization, electrocautery scoops out “chips” of prostatic tissue
Chips go into bladder and are evacuated and sent to pathology
Most older men only need one in a lifetime
ADE of TURP surgery are
Retrograde ejaculation
Hematuria TUR syndrome (hyponatremia, confusion, HTN, visual changes)
What is TUMT
Cath-like microwave device heats prostate and causes necrosis
Prostatic tissue sloughs and passes through urethra when patient voids
Temp is monitored rectally, pt is awake and outpt
What is TUIP
Cytoscopic incision made at 5 and 7 o’clock position of prostatic urethra from bladder neck to above verumontanum
Prostate springs open- NO tissue removed
Less chance of retrograde ejaculation
What is Urolift
Permanent implant in prostate
Anchored outside prostate capsule and inside prostatic urrethra
Widens urethral lumen
(clothes tags)
What is PVP
Similar to TURP but you can do it on anticoagulated patient!
Not as effective or long lasting as TURP
What is an open simple prostatectomy
Open suprapubic midline, incise prostate capsule, enucleate glandular adenoma, close capsule
Done on prostates >80g bc TURP would likely cause TUR syndrome (hyponatremia, HTN, confusion, vision change)
What is HoLEP
Transurethrally dont on large prostates (>80, 100, 200g)
