Urology: BPH & ED Flashcards
What is benign prostatic hypertrophy (BPH)?
A very common condition affecting men in older age (usually over 50 years).
It is caused by hyperplasia of the stromal and epithelial cells of the prostate.
How does BPH usually present?
Lower urinary tract symptoms:
- Hesitancy – difficult starting and maintaining the flow of urine
- Weak flow
- Urgency – a sudden pressing urge to pass urine
- Frequency – needing to pass urine often, usually with small amounts
- Intermittency – flow that starts, stops and varies in rate
- Straining to pass urine
- Terminal dribbling – dribbling after finishing urination
- Incomplete emptying – not being able to fully empty the bladder, with chronic retention
- Nocturia – having to wake to pass urine multiple times at night
What scoring system is used to assess the severity of lower urinary tract symptoms?
The international prostate symptom score (IPSS):
Score 20–35: severely symptomatic
Score 8–19: moderately symptomatic
Score 0–7: mildly symptomatic
What 6 investigations will be done in the initial assesment of a man presenting with LUTS?
1) Digital rectal exam: to assess the size, shape and characteristics of the prostate
2) Urinalysis: to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology
3) Abdo exam: to assess for a palpable bladder and other abnormalities
4) Urinary frequency volume chart: recording 3 days of fluid intake and output
5) PSA: for prostate cancer, depending on the patient age & preference
6) U&Es: particularly if chronic retention is suspected
Give some causes of a raised PSA
- Prostate cancer
- Benign prostatic hyperplasia
- Prostatitis
- Urinary tract infections
- Vigorous exercise (notably cycling)
- Recent ejaculation or prostate stimulation
Can BPH cause a raised PSA?
Yes
How does a benign prostate feel?
smooth, symmetrical and slightly soft, with a maintained central sulcus
How may a cancerous prostate feel?
may feel firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus
What are the 2 medical management options in BPH?
1) Alpha-blockers (e.g., tamsulosin)
2) 5-alpha reductase inhibitors (e.g., finasteride)
Role of alpha blockers (tamsulosin) in BPH?
Relaxes smooth muscle of prostate and bladder, with rapid improvement in symptoms.
Improve symptoms in around 70% of men
Role of 5-alpha reductase inhibitors (e.g., finasteride) in BPH?
Gradually reduce the size of the prostate
What is used to treat immediate symptoms in BPH?
Alpha blockers
What is used to treat enlargement of prostate in BPH?
5-alpha reductase inhibitors
Mechanism of 5-alpha reductase inhibitors?
5-alpha reductase converts testosterone to dihydrotestosterone (DHT), which is a more potent androgen hormone.
Inhibitors of 5-alpha reductase (i.e. finasteride) reduce DHT in the tissues, including the prostate, leading to a reduction in prostate size.
How long does it take for 5-alpha reductase inhibitors to work (improvement of symptoms)?
Up to 6 months
What are the 4 surgical options in BPH?
1) Transurethral resection of the prostate (TURP)
2) Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
3) Holmium laser enucleation of the prostate (HoLEP)
4) Open prostatectomy via an abdominal or perineal incision
What is the notable side effect of alpha blockers (tamsulosin)?
Postural hypotension
What should you check if an older man presents with lightheadedness on standing or falls?
1) check if they’re on tamsulosin
2) check their lying and standing blood pressure
What is the most notable side effect of finasteride?
Sexual dysfunction due to reduced testosterone
What is the most common surgical treatment of BPH?
Transurethral resection of the prostate (TURP)
What does TURP involve?
It involves removing part of the prostate from inside the urethra:
1) A resectoscope is inserted into the urethra
2) Prostate tissue is removed using a diathermy loop
3) The aim is to create a more expansive space for urine to flow through, thereby improving symptoms.
What are some major complications of TURP?
- Bleeding
- Infection
- Urinary incontinence
- Erectile dysfunction
- Retrograde ejaculation (semen goes backwards and is not produced from the urethra)
- Urethral strictures
- Failure to resolve symptoms
What does transurethral electrovaporisation of the prostate (TEVAP / TUVP) involve?
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.
What does holmium laser enucleation of the prostate (HoLE) involve?
Involves inserting a resectoscope into the urethra. A laser is then used to remove prostate tissue, creating a more expansive space for urine flow.
What is an open prostatecomy?
Involves an open procedure to remove the prostate. An abdominal or perineal incision can be used to access the prostate.
Open surgery is less commonly used as it carries an increased risk of complications, a more extended hospital stay and longer recovery than other surgical procedures.
What % of 50-year-old men will have evidence of BPH?
around 50% (and 30% will have symptoms)
What % of 80-year-old men will have evidence of BPH?
80%
What can LUTS be catagorised into?
1) voiding symptoms (obstructive)
2) storage (irritative)
3) post-micturition
4) complications
What are some examples of voiding LUTS?
weak or intermittent urinary flow
straining
hesitancy
terminal dribbling
incomplete emptying
What are some examples of storage LUTS?
urgency
frequency
urgency incontinence
nocturia
What are some examples of post-micturition LUTS?
Dribbling
What are some complications of LUTS?
urinary tract infection
retention
obstructive uropathy
When are alpha blockers indicated in BPH?
NICE recommend if moderate-to-severe voiding symptoms (IPSS ≥ 8)
Side effects of alpha blockers?
Dizziness, postural hypotension, dry mouth, depression
Mechanism of 5 alpha-reductase inhibitors e.g. finasteride?
block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH
When are 5 alpha-reductase inhibitors indicated in BPH?
Indicated if the patient has a significantly enlarged prostate and is considered to be at high risk of progression.
Adverse effects of finasteride?
erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia (due to reduction in testosterone)
Is combination therapy (alpha blocker + 5 alpha-reductase inhibitors) recommended in BPH?
Yes if required
There are a wide ranges of causes of erectile dysfunction (ED).
Name some:
Vascular: hypertension, atherosclerosis, hyperlipidemia, smoking
Neurological: Parkinson’s disease, multiple sclerosis, stroke, spinal cord injury, peripheral neuropathy
Hormonal: hypogonadism, hyperprolactinaemia, thyroid disease, Cushing’s disease
Drug-induced: antihypertensives, beta-blockers, diuretics, antidepressants, antipsychotics, anticonvulsants, recreational drugs, alcohol
Systemic disease: diabetes mellitus, renal failure
Structural: pelvic trauma, penile trauma, Peyronie’s disease
Psychogenic: depression, anxiety, performance anxiety, schizophrenia
How can you help to distinguish between organic vs. psychogenic causes of ED?
Ascertaining whether a patient is having normal or impaired nocturnal erections:
Psychogenic: normal erections during sleep
Organic: no evidence of erection
Investigations in ED?
1) Bloods: FBC, LFTs, U&Es, TFTs, lipid profile, fasting glucose and/or HbA1c, serum total testosterone
2) Calculate QRISK score (10-year cardiovascular risk)
Additional specialist tests (in complex or refractory ED):
1) Nocturnal penile tumescence testing (NPT)
2) Duplex doppler imaging/angiography
What should be explored in an ED history (history of presenting complaint)?
Patients with suspected ED will primarily complain of difficulties initiating or sustaining an erection.
1) Onset of sexual dysfunction (i.e. short, gradual)
2) Duration of sexual dysfunction (i.e. lifetime or acquired)
3) Difficulties with arousal
4) Rigidity of erections
5) Duration of sexual stimulation
6) Difficulties with ejaculation
7) Difficulties with orgasm
8) Presence/absence of morning/nocturnal erections
What is the International Index of Erectile Function (IIEF-5)?
An objective 5-item questionnaire frequently used by urologists to assess the severity of a patient’s ED.
1) How do you rate your confidence that you could get and keep an erection?
2) When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
3) During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?
4) During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
5) When you attempted sexual intercourse, how often was it satisfactory for you?
What should be explored in an ED history (wider background)?
PMH: previous sexual dysfunction, cardiovascular disease and previous pelvic surgery.
DH: antihypertensives, beta-blockers, diuretics, antidepressants, antipsychotics, and anticonvulsants.
Psych: current or previous psychological problems (e.g. depression, anxiety)
SH: smoking, alcohol consumption, illicit drug use, diet, exercise
Sexual history: current sexual partner(s), relationship status, partner’s reaction to ED
It is crucial to explore the patient’s relationships with their sexual partners. If the cause of ED is thought to be psychogenic, the nature of these relationships will allow you to better understand the origins of the dysfunction. Relationship stress has been implicated with sexual dysfunction in men.
How is a patient with ED’s QRISK calculated?
By measuring lipid and fasting glucose serum levels.
When should free testoterone be measured in ED?
Free testosterone should also be measured in the morning between 9 and 11am.
If free testosterone is low or borderline in ED, what is next ste?
It should be repeated along with FSH, LH and prolactin levels (for 2ary hypogonadism).
If any of these are abnormal refer to endocrinology for further assessment.
What test is used to distinguish between organic vs. psychogenic ED?
Nocturnal penile tumescence testing (NPT): the patient wears the NPT device overnight, measuring number, tumescence and rigidity of erections.
What test is used if a vascular cause of ED is suspected?
Duplex doppler imaging/angiography
Lifestyle management options in ED?
Should be encouraged to adopt healthy lifestyle behaviours, including smoking cessation, minimal alcohol intake, and weight loss.
Many of these risk factors are linked to cardiovascular disease and diabetes, among others, which are known to predispose to ED
Management options in ED?
1) Modification of risk factors
2) Psychosexual counselling
3) Phosphodiesterase-5 inhibitors
4) Hormone treatments
5) Penile prosthesis
1st line medical management of ED?
PDE-5 inhibitors e.g. sildenafil (‘Viagra’)
Who should PDE-5 inhibitors be prescribed to with ED?
they should be prescribed (in the absence of contraindications) to ALL patients regardless of aetiology
sildenafil can be purchased over-the-counter without a prescription.
1st line treatment in those who can’t/won’t take a PDE-5 inhibitor?
Vacuum erection devices
Mechanism of PDE-5 inhibitors?
These drugs inhibit PDE-5, allowing for the prolongation of cGMP and subsequent relaxation of penile blood vessels supplying the corpus cavernosum.
How long is sildenafil expected to last?
The drug is intended to last for roughly 4 hours (if an erection lasts longer than 4 hours, the patient should seek urgent care for risk of priapism)
When should patients taking sildenafil seek urgent medical advice?
Erection >4 hours
Main contraindication for PDE-5 inhibitors?
1) Concurrent nitrate use (risk of severe hypotension)
2) hypotension
3) recent stroke or myocardial infarction (NICE recommend waiting 6 months)
Main 2 indications of PDE-5 inhibitors?
1) Erectile dysfunction
2) Pulmonary HTN
When should sildenafil be taken?
short-acting - usually taken 1 hour before sexual activity
Side effects of PDE-5 inhibitors?
- visual disturbances: blue discolouration, non-arteritic anterior ischaemic neuropathy
- nasal congestion
- flushing
- gastrointestinal side-effects
- headache
- priapism
How can sildenafil change vision?
Can cause blue discolouration of vision
