Urology - BPH

Question 1

what is BPH?

Answer 1

Androgen-dependent hyperplasia of cells in transitional zone of prostate. Causes obstructive symptoms.

Question 2

what are the common symptoms of BPH?

Answer 2

1. urinary frequency and nocturia
2. urinary urgency
3. hesistancy - difficulty initiating urine flow, poor stream, dribbling of urine, need to push/strain, intermittency
4. incomplete bladder emptying

Question 3

how could you clinically assess severity of BPH?

Answer 3

1. DRE - assess size, texture and contour of prostate

2. IPPS (international prostate symptom score)

Question 4

which investigations would you perform in someone with suspected BPH?

Answer 4

Bloods:

• routine bloods: FBC, LFTs, UandEs and creatinine
• PSA: increase in variety of conditions

Urine:

• urine dipstick
• MSU for M and C

Question 5

how would you manage a pt with BPH pharmacologicaly?

Answer 5

1. alpha blockers, e.g. TAMSULOSIN - offered in moderate-severe voiding symptoms (IPSS 8+)
2. 5-a reductase inhibitors, e.g. FINASTERIDE or DUTASTERIDE - offered to men with LUTS and prostate estimated >30 g or PSA >1.4 ng/mL and high risk of progression. May take several mths before benefit noted but reduce long term risk of acute retention or need for surgery.

Combination of above can be offered in pts with moderate-severe LUTS not responding to monotherapy. Tx should be continued at least 1 yr.

Question 6

how can a pt with BPH be managed surgically?

Answer 6

Usually reserved for those with large prostates or acute urinary retention, failed voiding trials, recurrent gross haematuria, UTI, renal insufficiency due to obstruction or failure of medical treatment.

1. TRANSURETHRAL RESECTION OF PROSTATE (TURP)
2. Other options inc. insertion of prostatic urethral lift implants, holmium laser enucleation of prostate or open prostatectomy (if prostate >80g, bladder stones or bladder diverticula)

Question 7

what is TURP syndrome?

Answer 7

Rare but potentially lethal complication of TURP. Involves absorption of large amounts of irrigation fluid (usually glycine-based) through damaged venous sinuses.

Signs and symptoms varied, resulting from fluid overload (causing pulmonary and cerebral oedema), electrolyte imbalance esp. hyponatraemia and hyperammonaemia (by-product of glycine metabolism).

Question 8

suggest possible complications of BPH

Answer 8

Bladder outlet obstruction can result in:

• urinary retention - can be precipitated by anticholinergic drugs inc. TCAs, opiates and diuretics
• recurrent UTIs (esp. with incomplete emptying)
• impaired kidney function (progression to CKD now rare)
• bladder calculi
• haematuria

Question 9

describe the MOA of tamsulosin

Answer 9

a-blocker causing decreased prostate smooth muscle tone

Question 10

suggest characteristic side effects associated with tamsulosin

Answer 10

1. dizziness, postural hypotension
2. sexual dysfunction, inc. retrograde ejaculation

Risk of intraoperative floppy iris syndrome in cataract surgery.

Question 11

describe the MOA of finasteride

Answer 11

5a-reductase inhibitor - prevents metabolism of testosterone into dihydrotestosterone so reduces stimulatory effect of androgens on gland hyperplasia.

Question 12

suggest characteristic side effects associated with finasteride

Answer 12

1. sexual dysfunction
2. breast abnormalities, inc. gynaecomastia and male breast cancer
3. depression and suicidal thoughts