Revision - BPH & ED

Question 1

What scoring system is used to assess the severity of LUTS?

Answer 1

The International Prostate Symptom Score (IPSS)

Question 2

What are the 2 medical management options in BPH?

Answer 2

1) Alpha antagonists e.g. tamsulosin

2) 5a-reductase inhibitors e.g. finasteride

Question 3

Role of alpha blockers (tamsulosin) in BPH?

Answer 3

Relax smooth muscle of the prostate and bladder –> rapid improvement in symptoms.

Question 4

Role of 5-alpha reductase inhibitors (e.g., finasteride) in BPH?

Answer 4

Gradually reduce size of prostate (can take up to 6m to work)

Question 5

Mechanism of 5-alpha reductase inhibitors?

Answer 5

5a-reductase converts testosterone into dihydrotestosterone (DHT), which is a more potent androgen hormone.

Inhibitors of 5a-reductase (i.e. finasteride) reduce DHT in the tissues, including the prostate, leading to a reduction in prostate size.

Question 6

What is a surgical option in BPH?

Answer 6

Transurethral resection of the prostate (TURP)

Question 7

What is the notable side effect of alpha blockers (tamsulosin)?

Answer 7

Postural hypotension

Question 8

What is the most notable side effect of finasteride?

Answer 8

Sexual dysfunction due to reduced testosterone

Question 9

What are some major complications of TURP?

Answer 9

1) Bleeding

2) Infection

3) Urinary incontinence

4) Erectile dysfunction

5) Retrograde ejaculation (semen goes backwards and is not produced from the urethra)

6) Urethral strictures

7) Failure to resolve symptoms

8) TURP syndrome

Question 10

When are alpha blockers indicated in BPH?

Answer 10

NICE recommend if moderate-to-severe voiding symptoms (IPSS ≥ 8)

Question 11

When are 5 alpha-reductase inhibitors indicated in BPH?

Answer 11

Indicated if the patient has a significantly enlarged prostate and is considered to be at high risk of progression.

Question 12

Adverse effects of finasteride?

Answer 12

• erectile dysfunction
• reduced libido
• ejaculation problems
• gynaecomastia

(all due to reduced testosterone)

Question 13

What questionnaire can be used to assess the severity of a patient’s ED?

Answer 13

International Index of Erectile Function (IIEF-5)

Question 14

If free testosterone is low or borderline in ED, what is next step?

Answer 14

It should be repeated along with FSH, LH and prolactin levels (for 2ary hypogonadism).

Question 15

What test is used to distinguish between organic vs. psychogenic ED?

Answer 15

Nocturnal penile tumescence testing (NPT): the patient wears the NPT device overnight, measuring number, tumescence and rigidity of erections.

Question 16

1st line medical mx of ED?

Answer 16

PDE-5 inhibitors e.g. sildenafil

Question 17

Who should PDE-5 inhibitors be prescribed to with ED?

Answer 17

they should be prescribed (in the absence of contraindications) to ALL patients regardless of aetiology

Question 18

When should patients taking sildenafil seek urgent medical advice?

Answer 18

Erection >4 hours

Question 19

Main contraindication for PDE-5 inhibitors?

Answer 19

1) Concurrent nitrate use (risk of severe hypotension)

2) hypotension

3) recent stroke or myocardial infarction (NICE recommend waiting 6 months)

Question 20

Main 2 indications of PDE-5 inhibitors?

Answer 20

1) ED

2) Pulmonary HTN

Question 21

Side effects of PDE-5 inhibitors?

Answer 21

• visual disturbances: blue discolouration, non-arteritic anterior ischaemic neuropathy
• nasal congestion
• flushing
• GI side-effects
• headache
• priapism