BPH Flashcards
BPH occurrence
Affects 24% of men aged 40-64, 40% of men >60 years
BPH cause
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
BPH progression
Repeat healthcase visits
Retention risk + recurrent infection
BPH surgery costly
LUTS symptoms
Polyuria Nocturia Urgency Incontinence Hesitancy Intermittency Involuntary interruption of voiding Weak urinary stream Straining to void Dysuria Sensation of incomplete emptying Post-micturition dribbling
BPH assessment
general medical + drug history
Focused physical exam
Abdo exam + external genitalia + DRE
BPH investigations
Urine dipstick Frequency vol. chart IPSS PSA test Serum creatinine
PSA
Mandatory in men with LUTS suggestive of BPH obstruction or abnormal prostate on DRE
>4ug suggestive of prostate cancer?
Causes of increased PSA
DRE Sex BPH Infection/prostatitis UTI (wait 6 months for PSA to normalise) Age Urethral catheterisation Prostatic biopsy
BPH secondary care investigations
Cystoscopy
Imaging of upper urinary tract
Flow rate measurement- normal >15ml/sec
Post-voidal residual volume measurement
BPH management
Bothersome or complicate or IPSS >7
No–> active surveillance- reassurance, information, lifestyle
Yes –> Active intervention- conservative/drugs/surgery
BPH conservative management- storage symptoms
Fluid advice
Supervised bladder training
Lifestyle advice- less caffeine, carbonated drinks, alcohol
Containment products
BPH conservative management- voiding symptoms
Intermittent catheterisation
Urethral milking for post-micturition dribbling
BPH risk of progression
>70yrs + LUTS Moderate to severe symptoms (IPSS >7) PSA>1.4 Prostate estimated >30cm Flow rate<12ml
BPH drug management- moderate to severe
Alpha blocker (tamsulosin
BPH drug management- LUTS + prostate>30g or PSA>1.4 + high risk progression
5 alpha reductase inhibitor (finasteride)
BPH drug management- bothersome moderate to severe LUTS and prostate>30g or PSA>1.4
Alpha blocker + 5 alpha reductase inhibitor
BPH drug management- Storage symptoms despite treatment with alpha blocker alone
Consider adding anticholinergic
Alpha blockers example
Tamsulosin
Alpha blockers MOA
Works by relaxing smooth muscle of IUS, opposing the restriction on bladder neck outlet caused by enlarged prostate
Well tolerated
Alpha blockers SEs
Retrograde ejaculation
5 alpha reductase inhibitors e.g.
Finasteride
Dutasteride
5 alpha reductase inhibitors MOA
Blocks conversion of testosterone into DHT, stopping further enlargement of prostate
5 alpha reductase inhibitors SEs
Sexual dysfunction (ED, loss of libido)
Surgery offered if
Voiding symptoms severe
Conservative + drug management have been unsuccessful or are inappopopriate
Transurethral resection of prostate
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)
Holmium laser enucleation of prostate (HoLEP)
Modern laser operation
Less risk of transfusion + erection issues + no TURP syndrome
UroLift
Purely mechanical
Preserves erections
