BPH

Question 1

BPH occurrence

Answer 1

Affects 24% of men aged 40-64, 40% of men >60 years

Question 2

BPH cause

Answer 2

Benign nodular or diffuse proliferation of musculofibrous + glandular layers of prostate
Inner (transitional) zone enlarges in contrast to peripheral zone expansion seen in prostatic carcinoma
Experience LUTS

Question 3

BPH progression

Answer 3

Repeat healthcase visits
Retention risk + recurrent infection
BPH surgery costly

Question 4

LUTS symptoms

Answer 4

Polyuria
Nocturia
Urgency
Incontinence
Hesitancy
Intermittency
Involuntary interruption of voiding
Weak urinary stream
Straining to void
Dysuria
Sensation of incomplete emptying
Post-micturition dribbling

Question 5

BPH assessment

Answer 5

general medical + drug history
Focused physical exam
Abdo exam + external genitalia + DRE

Question 6

BPH investigations

Answer 6

Urine dipstick
Frequency vol. chart
IPSS
PSA test
Serum creatinine

Question 7

PSA

Answer 7

Mandatory in men with LUTS suggestive of BPH obstruction or abnormal prostate on DRE
>4ug suggestive of prostate cancer?

Question 8

Causes of increased PSA

Answer 8

DRE
Sex
BPH
Infection/prostatitis
UTI (wait 6 months for PSA to normalise)
Age
Urethral catheterisation
Prostatic biopsy

Question 9

BPH secondary care investigations

Answer 9

Cystoscopy
Imaging of upper urinary tract
Flow rate measurement- normal >15ml/sec
Post-voidal residual volume measurement

Question 10

BPH management

Answer 10

Bothersome or complicate or IPSS >7
No–> active surveillance- reassurance, information, lifestyle
Yes –> Active intervention- conservative/drugs/surgery

Question 11

BPH conservative management- storage symptoms

Answer 11

Fluid advice
Supervised bladder training
Lifestyle advice- less caffeine, carbonated drinks, alcohol
Containment products

Question 12

BPH conservative management- voiding symptoms

Answer 12

Intermittent catheterisation

Urethral milking for post-micturition dribbling

Question 13

BPH risk of progression

Answer 13

>70yrs + LUTS
Moderate to severe symptoms (IPSS >7)
PSA>1.4
Prostate estimated >30cm
Flow rate<12ml

Question 14

BPH drug management- moderate to severe

Answer 14

Alpha blocker (tamsulosin

Question 15

BPH drug management- LUTS + prostate>30g or PSA>1.4 + high risk progression

Answer 15

5 alpha reductase inhibitor (finasteride)

Question 16

BPH drug management- bothersome moderate to severe LUTS and prostate>30g or PSA>1.4

Answer 16

Alpha blocker + 5 alpha reductase inhibitor

Question 17

BPH drug management- Storage symptoms despite treatment with alpha blocker alone

Answer 17

Consider adding anticholinergic

Question 18

Alpha blockers example

Answer 18

Tamsulosin

Question 19

Alpha blockers MOA

Answer 19

Works by relaxing smooth muscle of IUS, opposing the restriction on bladder neck outlet caused by enlarged prostate
Well tolerated

Question 20

Alpha blockers SEs

Answer 20

Retrograde ejaculation

Question 21

5 alpha reductase inhibitors e.g.

Answer 21

Finasteride

Dutasteride

Question 22

5 alpha reductase inhibitors MOA

Answer 22

Blocks conversion of testosterone into DHT, stopping further enlargement of prostate

Question 23

5 alpha reductase inhibitors SEs

Answer 23

Sexual dysfunction (ED, loss of libido)

Question 24

Surgery offered if

Answer 24

Voiding symptoms severe

Conservative + drug management have been unsuccessful or are inappopopriate

Question 25

Transurethral resection of prostate

Answer 25

Electric loop carves out prostate chips
Can cause erection issues (14% incompetent) and TURP syndrome (absorption into prostatic venous sinuses of fluids used to irrigate bladder during operation)

Question 26

Holmium laser enucleation of prostate (HoLEP)

Answer 26

Modern laser operation

Less risk of transfusion + erection issues + no TURP syndrome

Question 27

UroLift

Answer 27

Purely mechanical

Preserves erections