BPH

Question 1

What is BPH

Answer 1

enlarged prostate in absence of malignancy

Question 2

Pathologically, how can BPH impede passage of urine leaving the bladder

Answer 2

• Glandular tissue grows into lumen of urinary tract

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

Question 3

What are Sx of LUTS (lower urinary tract symptoms)

Answer 3

weak stream 
hesitancy 
stream intermittency 
post void dribbling 
nocturia

Question 4

Other than LUTS, how will BPH usually present

Answer 4

Urinary retention
Recurrent UTI
Hx of cystolithiasis

Question 5

What scoring systems can be used to evaluate BPH

Answer 5

AUA symptom score (0-35) for urinary Sx 
Bother index (0-6) for impact on QOL

Question 6

What prostatic abnormalities should you look for on DRE for BPH

Answer 6

Indurated 
Firm
Boggy
Nodular 
\+/- tenderness

Question 7

What urologic labs can we get to evaluate BPH

Answer 7

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

Question 8

How do you treat BPH (categories)

Answer 8

Watchful waiting (monitor Sx, recheck labs prn)
Lifestyle modification
Meds
Surgery

Question 9

What lifestyle modifications can help treat BPH

Answer 9

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)

Question 10

What meds can be used to Tx BPH (categories)

Answer 10

Phytotherapy (Saw palmetto)
Alpha blockers
5 alpha reductase inhibitors

Question 11

What is the MOA of Alpha blockers

Answer 11

Block alpha 1 receptors in the bladder and prostatic stroma= relax smooth muscle= free passage of urine

Question 12

What are the alpha 1 blockers

Answer 12

Terazosin
Doxazosin
-Alpha 1A blockers are more specific to urine effects and dont affect BP and nasal passages: Tamsulosin (flomax), Silodosin, Alfuzosin

Question 13

ADE of Alpha blockers include

Answer 13

*Dizziness
*Retrograde ejaculation
*Inoperative floppy iris syndrome
Orthostatic hypotension
asthenia, congestion

Question 14

Who are alpha blockers CI in

Answer 14

patients about to have cataract surgery

Question 15

What is the MOA of 5ARI

Answer 15

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

Question 16

Are 5ARI effects immediate

Answer 16

No, can take up to 6 months!
But you should see PSA decrease by about 50%
Possibly stops chronic hematuria 2/2 prostatic varicies

Question 17

What are the 5ARI

Answer 17

Finasteride

Dutasteride

Question 18

ADE of 5ARI include

Answer 18

Impotence 
Decreased libido 
low ejaculatory volume 
gynecomastia 
(low DHT!)

Question 19

What is preferred med combo to treat BPH

Answer 19

Alpha blocker + 5ARI
(Tamulosin + Dutasteride)
a-blocker gives early response to appease patient, while 5ARI takes time to kick in

Question 20

What is the only medication FDA approved for treating BPH

Answer 20

Radalafil (cialis), a PDE5 inhibitor (technically isoenzyme 11 per brubs)

Question 21

What surgeries are available for BPH

Answer 21

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

Question 22

Gold standard surgical treatment for BPH is

Answer 22

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

Question 23

ADE of TURP surgery are

Answer 23

Retrograde ejaculation

Hematuria TUR syndrome (hyponatremia, confusion, HTN, visual changes)

Question 24

What is TUMT

Answer 24

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

Question 25

What is TUIP

Answer 25

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

Question 26

What is Urolift

Answer 26

Permanent implant in prostate
Anchored outside prostate capsule and inside prostatic urrethra
Widens urethral lumen
(clothes tags)

Question 27

What is PVP

Answer 27

Similar to TURP but you can do it on anticoagulated patient!
Not as effective or long lasting as TURP

Question 28

What is an open simple prostatectomy

Answer 28

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)

Question 29

What is HoLEP

Answer 29

Transurethrally dont on large prostates (>80, 100, 200g)