Surgery: BPH and Prostate Cancer Flashcards
How common BPH is?
50% men aged over 60
Lower urinary tract symptoms that may present in BPH
- Sensation of incomplete emptying of bladder
- Frequency – urinating every 2 hours or less
- Intermittency – stop/start stream
- Hesitancy
- Urgency – difficult to postpone urination
- Nocturia – number of times urinating at night
- Weak stream
- Straining
(2) ways of medical management of BPH
- Alpha-Blockers (e.g. Tamsulosin)→ relax smooth muscle of prostate
- 5 - alpha - reductase inhibitors (e.g. FInasteride)→ block the metabolism of testosterone *this is used if Tamsulosin does not work
Tamsulosin
- how quickly it should work
- side effects
Tamsulosin (alpha-blocker →smooth muscle relaxation)
- should provide symptomatic benefit within few days
- Side effects: postural hypotension, rhinitis, retrograde ejaculation, Floppy Iris Syndrome (if undergoing cataract surgery), lack of energy
Finasteride
- how long it would take to work
- common side effects
Finasteride (5 alpha-reductase inhibitor) → less testosterone is converted to DHT
- can take up to 6 months for symptomatic benefit
- side effects: sexual dysfunction (impotence - common), breast changes (uncommon)
What’s TURP?
Surgical management of BPH (considered if medical treatment fails)
TransUrethral Resection of the Prostate (TURP)
What does TURP involve?
Endoscopic removal of obstructive prostate tissue using a diathermy loop to increase the urethral lumen size
Possible complications of TURP
- haemorrhage
- sexual dysfunction
- retrograde ejaculation
- urethral stricture
What’s HoLEP?
HoLEP is the surgical option for management of BPH
Holmium Laser Enucleation of the Prostate (HoLEP)
What does HoELP involve?
- Holmium:YAG laser used to heat and dissect sections of prostate into the bladder
- it is becoming increasing more prevalent in use due to excellent outcomes and reduced post-operative complications
- its use only being limited due to it being a technically challenging procedure
What are possible complications of BPH?
- high-pressure retention → urinary retention → post-renal kidney injury
- recurrent UTIs
- significant haematuria episodes
What’s TURP syndrome?
- potentially life-threatening complication of TURP surgery
- TURP using monopolar energy requires use of hypoosmolar irrigation during the procedure which can result in significant fluid overload and hyponatremia as the fluid enters the circulation through the exposed venous beds
TURP syndrome
- presentation
TURP syndrome (fluid overload and hyponatremia)
- confusion
- nausea
- agitation
- visual changes
Management of TURP syndrome
- address the fluid overload
- carefully reduce the level of hyponatremia
What is the management option for a patient with prostatic obstruction and unsuitable for TURP?
Long-term management with catheter:
- Long term indwelling catheter (LTC)
- Intermittent self-catheterisation (ISC)
Complications of catheter
- UTI
- catheter erosion
- Haematuria
- calculus formation
- inconvenience
Non-modifiable risk factors for prostate cancer (4)
- Age → the incidence of prostate cancer increases with age
- Ethnicity → black African or Caribbean ethnicity twice as likely (one in four) to be diagnosed with prostate cancer in their lifetime when compared to white Caucasian men
- Family history of prostate cancer → but only 9% of prostate cancers are thought to be truly inherited
- BRCA2 or BRCA1 gene are at greater risk.
Modifiable risk factors of prostate cancer
- obesity
- diabetes mellitus
- smoking (associated with increased risk of prostate cancer death)
- degree of exercise (considered protective)
Clues from History that may point to prostate cancer
History
- LUTS (lower urinary tract symptoms)
- Bone pain
- Haematuria
- Family history
Clinical examination of prostate cancer (2)
- Digital rectal examination (DRE)
- Palpable bladder
Possible presentation/symptoms of prostate cancer
LUTS → weak urinary stream, increased urinary frequency, and urgency
More advanced localised disease may also cause:
- haematuria
- dysuria
- incontinence
- haematospermia
- suprapubic pain, loin pain
- rectal tenesmus
Any metastatic disease may cause:
- bone pain
- lethargy
- anorexia
- unexplained weight loss
Differential diagnosis of prostate cancer (3)
- Benign prostatic hyperplasia (BPH) → cause LUTS symptoms initially
- Prostatitis → present with perineal pain, with neutrophils seen on urinalysis
- Other causes of haematuria: these may include bladder cancer, urinary stones, urinary tract infections and pyelonephritis