BPH

Question 1

What is the arterial blood supply of the prostate?

Answer 1

PROSTATIC ARTERY

Question 2

What is the venous drainage of the prostate gland?

Answer 2

prostatic venous plexus -> internal iliac veins

-> internal vertebral venous plexus

Question 3

What is the innervation of the prostate gland?

Answer 3

inferior hypogastric plexus

Question 4

What are the causes of BPH?

Answer 4

• hormones -> increased estrogen & decreased testosterone
• growth factors -> secretion of intermediate peptide growth hormones
• genetic factors

Question 5

What is the pathophysiology of BPH?

Answer 5

develops in middle transitional zone (outer peripheral zone in prostatic cancer)

hyperplasia -> hyperplastic nodule smooth & firm -> slit like urethral compression -> BOO (bladder outlet obstruction)

Question 6

What are the clinical features of BPH?

Answer 6

STORAGE irritative symptoms

• frequency
• urgency
• urge incontinence
• nocturia

VOIDING obstructive symptoms

• straining
• hesitancy
• intermittency
• poor stream
• terminal dribbling

symptoms of superimposed infections

• dysuria
• hematuria
• constitutional symptoms

incomplete emptying & chronic or acute urinary retention

Question 7

What is felt on DRE?

Answer 7

• symmetrically enlarged prostate
• smooth & firm
• nontender
• rubbery or elastic texture

Question 8

What investigations should be done for patient with BPH?

Answer 8

• Urinalysis for all patients with LUTS

if abnormal findings -> urine culture

Question 9

What is the importance of serum PSA level?

Answer 9

use in suspected prostate cancer

• 1.5 ng/mL -> enlarged prostate
• 4 ng/mL -> prostate cancer

Question 10

What is the benefit of urodynamic studies?

Answer 10

helps identify the predominant type of LUTS

storage vs voiding

Question 11

What are the indications of PVR?

Answer 11

• all patients with suspected BOO
• before treatment with antimuscarinic
• baseline before surgery

findings

• > 50ml is abnormal
• > 300ml -> urinary retention

Question 12

How should BPH be managed?

Answer 12

1- watchful waiting
2- medical therapy -> alpha blocker for symptoms (zosins & tamsulosin)
-> 5 alpha reductase blockers to decrease size (Finasteride & Dutasteride)
3- surgical management

Question 13

What are the side effects of alpha 1 blockers?

Answer 13

• orthostatic hypotension
• dizziness
• syncope
• tiredness
• peripheral edema
• headache
• ejaculatory problems
• nasal congestions

Question 14

What are the side effects of 5 alpha reductase blockers?

Answer 14

• ED
• decreased libido
• gynecomastia

Question 15

What are the indications of surgical intervention?

Answer 15

TRANSURETHRAL RESECTION OF THE PROSTATE in

• recurrent urinary retention
• recurrent UTIs
• renal insufficiency
• bladder calculi
• recurrent gross hematuria
• failure of medical therapy

Question 16

What are the complications of transurethral resection of the prostate?

Answer 16

• retrograde ejaculation
• recurrent UTI
• urinary retention with bladder distention & bladder wall hypertrophy
• bladder calculi
• hydronephrosis
• chronic kidney disease

Question 17

What is the preferred agent to be used in case of LUTS cause by BOO (bladder outlet obstruction)?

Answer 17

• small prostate (<40mL) or serum PSA <1.5ng/ml -> alpha blocker
• large prostate (>40mL) or serum PSA >1.5ng/ml -> 5-alpha reductase inhibitors
• severe symptoms or no response to therapy -> BOTH a blockers & 5-a reductase inhibitors

Question 18

What is the preferred agent to be used in case of LUTS cause by OAB (over active bladder)?

Answer 18

antimuscarinic

Question 19

What is the preferred agent to be used in case of LUTS caused by BOO & OAB?

Answer 19

alpha blocker & antimuscarinic

Question 20

What is the preferred agent to be used in case of LUTS associated with erectile dysfunction?

Answer 20

phosphodiesterase 5 inhibitor

Question 21

What are the mechanical causes of urinary retention?

Answer 21

• enlarged prostate
• urethral narrowing
• bladder neck obstruction
• extrinsic obstruction
• urethral/bladder trauma

Question 22

What are the functional causes of urinary retention?

Answer 22

• detrusor underactivity &/or sphincter overactivity (neurogenic bladder or drug induced)
• detrusor-sphincter dyssynergia
• bladder neck dysfunction
• postoperative urinary retention

Question 23

What are the clinical features of urinary retention?

Answer 23

acute

• sudden onset > 70 years
• painful inability to void
• suprapubic pain
• palpable bladder
• patient is restless and distressed

chronic

• more in males
• painless incomplete voiding
• may have palpable bladder
• overflow incontinence or nocturnal enuresis

Question 24

How is urinary retention treated?

Answer 24

AUR -> SURGICAL EMERGENCY -> Bladder decompression (urethral or suprapubic)

treat the cause

• stricture -> dilatation
• BPH -> medication

Question 25

What are the complications of urinary retention?

Answer 25

Acute -> renal failure

Chronic

• > UTI
• > vesicoureteric reflux -> hydronephrosis -> renal failure
• > urolithiasis
• > overflow incontinence

Bladder decompression

• > hematuria
• > transient hypotension
• > postobstructive diuresis