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MET3b > BPH > Flashcards

BPH Flashcards

1
Q

Characteristics of BPH

A
  • benign enlargement of prostate
  • may result in range of lower urinary tract symptoms = bothersome and impact QoL
  • males 50 and over prevalence
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2
Q

LUTS examples

A
  • need to pass urine often without warning
  • waking up in night to urinate
  • feeling that bladder is not empty after been toiler
  • weak urine stream
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3
Q

How to assess LUTS

A
  • IPSS (International Prostate Symptom Score)
  • 0-35 range
  • higher score = worse symptoms
  • mild = 0-7
  • moderate = 8-19
  • severe = 20-35
  • allows assessment of symptom change
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4
Q

ST Consequences of BPH progression

A
  • pain
  • financial cost
  • recurrent hospitalisation
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5
Q

LT Consequences of BPH progression

A
  • surgery likelihood
  • increased complication risk
  • risk of recurrent retention
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6
Q

NICE 10 key priorities for initial assessment

A

1) General medical history to identify causes of LUTS and associated comorbidities
2) physical exam (abdomen, external genitalia and DRE)
3) bothersome LUTS = urinary frequency volume chart
4) if LUTS complicated by recurrent/persistent UTIs, retention, renal impairment, urological cancer suspected = specialist assessment
9) ensure access to care for physical, emotional, psychological, sexual and social issues
10) If storage LUTS (incontinence) = provide containment products and advice about support groups

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7
Q

Main LUTS

A 
VOIDING
- weak/intermittent urinary stream
- straining
- hesitancy
- terminal dribbling
- incomplete emptying
STORAGE
- urgency
- frequency
- incontinence
- nocturia
POST-MICTURITION
- dribbling
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8
Q

Investigations NICE

A
  • urine dipstick
  • frequency volume chart
  • PSA
  • serum creatinine (if indications of renal impairment)
  • IPSS baseline symptom assessment
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9
Q

Frequency Volume Charts

A
  • voiding diaries
  • severity of symptoms
  • at initial and specialist assessment complete
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10
Q

Assessing prostate size

A
  • walnut (normal) = 3.2cm diameter
  • ping pong ball = 4cm
  • golf ball = 4.3
  • clementine = 5cm
  • tennis ball = 6.3cm
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11
Q

DRE

A
  • essential
  • symmetry, size, firmness, surface smoothness, tenderness, midline groove
  • soft smooth enlarged benign
  • hard woody irregular carcinoma
  • assess also rectum and pelvis for faecal loading/impaction/rectal tumours/other pelvic masses
  • NICE advice as part of initial assessment
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12
Q

Urinalysis

A
  • first line investigation
  • haematuria, glycosuria, proteinuria, pyuria, nitrites, leucocytes
  • screening
  • abnormalities need to be confirmed by MSU then microscopy and culture
  • microscopy reveals bacteria, leucocytes, erythrocytes, cellular casts
  • initial assessment
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13
Q

PSA testing

A
  • offer info, advice and time to decide is they wish to have test
  • if = prostate cancer concern, feels abnormal on DRE, LUTS suggest bladder obstruction secondary to BPE
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14
Q

What should not be routinely offered on initial assessment?

A
  • cystoscopy (unless evidence of bladder abnormality)
  • imaging of upper urinary tract (unless evidence of bladder abnormality)
  • flow rate measurement
  • post void residual volume measurement
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15
Q

NICE Conservative Management Priorities

A
  • offer men with storage LUTS (urinary incontinence) temporary containment products (pads/collecting devices) = social continence until management plan
  • offer supervised bladder training, fluid intake advice, lifestyle advice, containment products if overactive bladder
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16
Q

Aims of treatment in BPH

A
  • improve LUTS (voiding and storage)
  • improve QoL
  • prevent severe BPE/BPO related complications
17
Q

How to manage mild/moderate LUTS?

A
  • if bothersome symptoms = active intervention (baseline assessment IPSS and conservative management/drug/surgery)
  • if not bothersome = active surveillance (reassurance, advice on lifestyle interventions, info on condition, review if symptoms change)
18
Q

Storage symptoms management

A
  • supervised bladder training
  • fluid intake advice
  • lifestyle advice
  • containment products
  • pelvic floor muscle training if caused by prostactectomy
19
Q

Voiding symptoms management

A
  • intermittent bladder catheterisation before indwelling urethral or suprapubic catheterisation if less invasive measures do not correct
  • if bladder outlet obstruction bladder training less effective than surgery
  • urethral milking explain if post micturition dribble
20
Q

LUTS Drug Treatments

A
  • mod-severe = alpha blocker
  • LUTS + prostate >30g or PSA>1.4 + high progression risk = 5 alpha reductase inhibitor
  • mod-severe LUTS + >30g or PSA>1.4 = combination treatment
21
Q

Mechanism of 5 alpha reductase inhibitors

A
  • decrease dihydrotestosterone synthesis
  • reduced androgenic drive of prostate
  • reduction on prostate volume = improved outflow
  • LUTS 3-6m improve
  • finasteride = inhibits 5AR type II isoenzyme
  • dutasteride = dual inhibitor both type I and II isoenzymes
  • if risk of BPH progression
  • side effects of sexual function
22
Q

Mechanism of alpha blockers

A
  • block alpha1-adrenergic receptors in prostate, urethra, bladder neck and detrusor muscle
  • relaxation of SM = improved urinary flow
  • well tolerated
  • no effect on disease progression
23
Q

Medical therapy options of symptomatic BPH

A
  • alpha blocker
  • dutasteride
  • combination therapy (alpha blocker + 5ARI)
  • finasteride (mono 5ARI)
24
Q

RF for progressive disease

A
  • > 70 years
  • IPSS >7
  • PSA>1.4ng/ml
  • prostate volume > 30ccs (DRE enlarged)
  • flow rate <12ml/sec
25
Q

Efficiency of combination therapy

A
  • superior to Tamsulosin

- not superior to dutasteride

26
Q

Drug treatment for storage symptoms

A
  • overactive bladder = anticholinergic

- storage symp despite alpha blocker = add cholinergic

27
Q

When to review drug treatment?

A
  • to assess symptoms, effect of drug on QoL, adverse effects
  • alpha blockers = 4-6w then every 6-12m
  • 5ARI = 3-6m then every 6-12m
  • anticholinergic = 4-6w until stable, then every 6-12m
28
Q

When to refer to specialist assessment?

A
  • bothersome LUTS not responded to treatment/conservative management
  • LUTS complicated by recurrent UTIs/retention/renal impairment
  • urological cancer suspected
  • stress urinary incontinence
29
Q

How to manage acute urinary retention?

A
  • immediately catheterise

- offer alpha blocker before withdrawing catheter

30
Q

Surgery for voiding symptoms NICE

A
  • if for managing voiding LUTS presumed 2ndry to BPE = TURP, TUVP, HoLEP
  • do not offer TUNA, TUMT, HIFU, TEAP or any other minimally invasive treatments
  • only offer if severe symptoms and other drugs and conservative management unsuccessful
31
Q

Surgery for storage symptoms

A
  • only if not responded to other
  • discuss alternatives of containment
  • inform effectiveness/side effects/LT risks

MET3b (20 decks)

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