Urology - BPH

Question 1

What is the patio physiology of PBH?

Answer 1

• Benign modular or diffuse hyperplasia of stromal and epithelial cells
• Affects inner (transitional) layer of prostate and leads to urethral compression
• Stromal cells use 5 alpha-reductase enzyme to produce DHT from testosterone
• DHT induces growth factors, which increases the number of stromal cells and decreases epithelial cell death

Question 2

BPH: presentation - storage symptoms

Answer 2

-Nocturia, frequency, urgency, overflow incontinence

Question 3

BPH: presentation - voiding symptoms

Answer 3

• hesitancy, straining, poor stream/flow + terminal dribbling, strangury (urinary tenesmus), incomplete emptying.
• Bladder stones and UTIs (secondary to stasis)

Question 4

BPH: examination

Answer 4

• PR: smoothly enlarged prostate, definable median sulcus
• Bladder is not normally palpable unless acute on chronic obstruction
• Should note size and consistency

Question 5

BPH: Ix

Answer 5

• Urine: dipstick and cultures
• Blood: U&Es and PSA
• DRE
• Imaging: transracial US +/- biopsy pr
• Urine flow test: generates graph of urinary volume against time + use US to determine residual bladder volume and look for upper tract dilatation)
• Urodynamics: look at bladder pressure - use cystoscopy and can see if there is a urethral stricture, bladder calculus or irritation symptoms

Question 6

BPH: Mx - conservative

Answer 6

• Decreasing caffeine and alcohol intake
• double voiding
• bladder training: make pt hold on and increase time between voiding

Question 7

BPH: Mx - medical (when?)

Answer 7

• Useful in mild disease and while awaiting TURP (no evidence of bladder outflow obstruction: hydronephrosis, recurrent UTIs, retention)
• 1st line: adrenoceptor blockers (eg Tamsulosin), which relax prostatic SM and increase urinary flow to help with the obstructive problems (S/E include drowsiness, decreased BP, increased wt, depression and extra pyramidal signs)
• 2nd line: 5 alpha-reductase inhibitors (eg Finasteride), which block the conversion of testosterone to a more active DHT

Question 8

BPH: Mx - outline 5 possibilities for surgical TRX

Answer 8

• TURP
• Transurethral incision of prostate (TUIP): similar benefits to TURP but needs to be smaller prostate, less destruction is caused t/g there is a decreased risk of impotence
• Laser prostatectomy: similar efficacy to TURP, decreases risk of retrograde ejaculation
• Transurethral electroVaporisation of prostate
• Open retropubic prostatectomy: used for huge (>100mg) prostates

Question 10

BPH: Mx - Indicators fo surgical Mx

Answer 10

• Symptoms affect QoL

- Complications from BPH - Bladder outflow obstruction (obstructive and voiding symptoms)

Question 11

Outline some early and late S/E of TURP

Answer 11

• Early: septic shock, bleeding and transurethral syndrome (leads to electrolyte imbalances, haemolysis, fluid overload and brain oedema)
• Late: secondary haemorrhage, urethral strictures, importance, recurrent prostate regrowth and (main problem) retrograde ejaculation (= infertility)

Question 12

What does TURP stand for? Outline procedure briefly

Answer 12

• Trans urethral resection of the prostate
• Pt placed in lithotomy position and resectoscope is passed through urethra and is used to remove the prostate piece by piece using diathermy (chippings sent to histology)