Urology: BPH Flashcards
Define BPH [1]
Increase in the size of the prostate WITHOUT the presence of malignancy
Which patient populations (apart from older men) is BPH more common in? [1]
Affects Afro-Caribbean’s more severely than white men, probably due to the high levels of testosterone
State the male LUTS from BPH that can be split into voiding [5], storage [4] and post micturition symptoms [1].
Voiding:
SHITE
- Straining
- Hesitancy
- Intermittant stream
- Terminal dribbling
- (incomplete) emptying
Storage:
- Urgency
- Frequency
- Incontinence
- Nocturia
Post mic:
- Dribbling (more delayed than terminal dribbling)
Investigations for BPH? [5]
- Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate
- Abdominal examination to assess for a palpable bladder and other abnormalities
- Urinary frequency volume chart, recording 3 days of fluid intake and output
- Urine dipstick to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology
- Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference
- IPSS
Mild, moderate and severe IPSS scores? [3]
- Mild symptoms 0 - 7
- Moderate 8 – 19
- Severe 20-35
Which prostate zone is enlarged in BPH? [1]
transitional zone
What is the max flow rate score that is suggestive of bladder outflow obstruction due to BPH? [1]
Max flow rate < 10ml per second is suggestive of bladder outflow obstruction due to BPH
State two complications of not treating BPH [2]
Renal failure: post-renal AKI
Severe UTI leading to sepsis
How do you treat patient with BPH with minimal symptoms? [1]
- If symptoms are minimal then: watchful waiting and advise lifestyle changes
What IPSS score would you offer treatment for BPH? [1]
> 7
What technique can assist with post mic dribbling? [1]
Urethral milking
What are the drug treatment options & order for BPH w/ bothersome symptoms but no indications for surgery? [4]
FIRST LINE: for moderate to severe LUTS
- Alpha 1 antagonists e.g. ORAL TAMSULOSIN
- 5-alpha-reductase inhibitor e.g. ORAL FINASTERIDE / DUTASTERIDE
- phosphodiesterase-5 (PDE-5) inhibitor: tadalafil
- anticholinergics: oxybutynin; tolterodine; solifenacin
Second line:
- Combine alpha 1 antagonist and 5-alpha reductase inhibitor
LUTS + what size prostate [1] or PSA score [1] would you move to second line treatment for BPH? [1]
- Prostate larger than 30g
- PSA > 1.4
BPH Treatment:
The general idea is that [] are used to treat immediate symptoms, and [] are used to treat enlargement of the prostate.
They may be used together where patients have significant symptoms and enlargement of the prostate.
The general idea is that alpha-blockers are used to treat immediate symptoms, and 5-alpha reductase inhibitors are used to treat enlargement of the prostate.
They may be used together where patients have significant symptoms and enlargement of the prostate.
Describe the MoA of finasteride [4]
5-alpha-reductase inhibitor:
* Blocks conversion of testosterone to DHT;
* DHT is considered to be the primary androgen playing a role in the development and enlargement of the prostate gland. It serves as the hormonal mediator for the hyperplasia upon accumulation within the prostate gland
Describe the MoA of tamulosin [3]
Alpha blocker:
* Blockade of α1-adrenergic receptors in prostate, urethra, bladder neck and detrusor muscle
* Relaxation of smooth muscle resulting in improved urinary flow
What is important to note about alpha blockers when treating BPH? [1]
Treat LUTS but don’t stop progression of BPH; no effect on size of the prostate
State 5 risk factors for progressive disease of BPH [5]
- Age over 70 with LUTS
- Moderate to severe symptoms i.e. IPSS>7
- PSA>1.4ng/ml
- Prostate volume over 30ccs (i.e.feels enlarged on DRE)
- Flow rate < 12ml/sec
Inhibition of 5AR prevents conversion of [] to [] and slows disease progression
Inhibition of 5AR prevents conversion of testosterone to DHT and slows disease progression
Name two side effects of BPH therapy [2]
ED
Retrograde ejaculation
What is the most common congenital male reproductive disorder?
Testicular torsion
Cryptorchidism
Hydrocoele
Peyronie disease
What is the most common congenital male reproductive disorder?
Testicular torsion
Cryptorchidism
Hydrocoele
Peyronie disease
Which of the following statements correctly defines priapism?
Inability to void the bladder
Abnormal curvature of the penis
Cyst due to a dilated testicular duct
Painful erection lasting more than 4 hours
Which of the following statements correctly defines priapism?
Inability to void the bladder
Abnormal curvature of the penis
Cyst due to a dilated testicular duct
Painful erection lasting more than 4 hours
A patient presents with symptoms of an overactive bladder.
What is the first choice drug treatment? [1]
What treatment is offered if the first choice is contrindicated? [1]
First choice: Oxybutynin
Second choice: Mirabegron
What is a positive Prehn’s sign? [1]
Which two pathologies does it help to distinguish between? [2]
+ve Prehn’s sign:
- the relief of pain on elevation of the testis
- Positive: indicates epididymo-orchitis
- Negative (i.e. the pain is not relieved) in cases of testicular torsion.
Describe the surgical treatments for BPH
Trans-urethral resection of prostate (TURP)
TOM TIP:
The notable side effect of tamsulosin is [].
The most common side effect of finasteride is [] (due to reduced []).
TOM TIP: The notable side effect of alpha-blockers like tamsulosin is postural hypotension. If an older man presents with lightheadedness on standing or falls, check whether they are on tamsulosin and check their lying and standing blood pressure.
The most common side effect of finasteride is sexual dysfunction (due to reduced testosterone).
1.
Describe surgical treatment for BPH [5]
Transurethral resection of prostate (TURP):
* GOLD STANDARD
* Less than 14% impotent, 1% incontinent & 10% erectile
dysfunction
Transurethral incision of prostate (TUIP):
* Less destruction than TURP and less risk to sexual function, best for smaller prostate
Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
- involves inserting a resectoscope into the urethra. A rollerball electrode is then rolled across the prostate, vaporising prostate tissue and creating a more expansive space for urine flow.
Holmium laser enucleation of the prostate (HoLEP)
- also involves inserting a resectoscope into the urethra. A laser is then used to remove prostate tissue, creating a more expansive space for urine flow.
Open prostatectomy via an abdominal or perineal incision
What drug class should be given if have overactive bladder? [1]
Add anti-cholinergic drug
Name two anti-cholinergics used for storage symptoms? [2]
- Oxybutynin
- Tolterodine
Describe the MoA of Oxybutynin, Tolterodine [3]
Competitively inhibits acetylcholine, blocking the muscarinic receptors and
promoting bladder relaxation to increase capacity
This reduces urgency and frequency of urination
These muscarinics are selective for M3 receptor which is the main receptor in the bladder
How do you manage acute urinary retention? [4]
- Immediately catheterise;
- Provide alpha blocker (e.g. tamulosin);
- Wait 24hr and remove catheter;
- (If still can’t urinate - schedule for TURP)
inflammation of the kidney resulting from bacterial infection. The inflammation affects the kidney tissue (parenchyma) and the renal pelvis (where the ureter joins the kidney).
Describe the pathophysiology of TURP syndrome? [3]
How serious is it? [1]
It is caused by irrigation with large volumes of glycine, which is hypo-osmolar and is systemically absorbed when prostatic venous sinuses are opened up during prostate resection
This results in hyponatremia, and when glycine is broken down by the liver into ammonia, hyper-ammonia and visual disturbances.
TURP syndrome is a rare and life-threatening complication
Desribe the early presentation [2] and late presentation [5]of TURP syndrome [2
TURP syndrome typically presents with CNS, respiratory and systemic symptoms:
Early features
* mild cases may go unrecognised
* restlessness, headache, and tachypnoea, or a burning sensation in the face and hands
Features of greater severity
* respiratory distress, hypoxia, pulmonary oedema
* nausea, vomiting
* visual disturbance (e.g. blindness, fixed pupils)
* confusion, convulsions, and coma
* haemolysis
* acute renal failure
* reflex bradycardia from fluid absorption
Pneumonic for TURP complications? [4]
Complications of Transurethral Resection: TURP
T urp syndrome
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate
TURP presents classically as a triad of? [3]
The triad of features are:
1. Hyponatraemia: dilutional
2. Fluid overload
3. Glycine toxicity
How long does finasteride need to be given for results to be seen? [1]
Finasteride treatment of BPH may take 6 months before results are seen
Name two side effects of tamulosin for treating BPH [2]
Dizziness
Postural hypotension
Name 4 side effects of finasteride for treating BPH [4]
erectile dysfunction
reduced libido
ejaculation problems
gynaecomastia
[] is the most effective management option in renal cell carcinoma? [1]
Radical nephrectomy is the most effective management option in renal cell carcinoma - RCC is usually resistant to radiotherapy or chemotherapy
