BENIGN PROSTATIC HYPERTROPHY Flashcards
DDx
• Prostate CA
• Prostatitis
• Bladder Stones
• Interstitial Cystitis
• UTI
• Urethral stricture
Clinical Features
Voiding / Obstruction - predominant in bladder outlet obstruction (BOO) secondary to BPH
Hesitancy, Weak Stream, Intermittence, Straining
Storage - r/o overactive bladder (OAB)
Urgency, Frequency, Urgency Incontinence, Nocturia
Postmicturition
Dribbling, Incomplete Emptying
What symptom score can be used?
International Prostate Symptom Score (IPSS)
Risk Factors
Age, obesity, diabetes, family history
Physical Exam Maneuvers
Suprapubic abdominal tenderness
Neuro (motor/sensory of perineum and lower limbs)
DRE
Investigations
Urinalysis +/- culture (r/o infection)
PSA
PVR if considering anticholinergics (eg. storage symptoms suggesting OAB)
Management of Nocturnal Polyuria
Voiding/Frequency chart 2-3 days
If urine output ≥3L
Decreased intake, aim for urine output 1L
If nocturnal urine output >33% nocturnal polyuria diagnosed
Consider Desmopressin
Management of Mild (IPSS < 8) BPH
Fluid restriction particularly prior to bedtime
Avoidance of alcohol, caffeine, spicy foods
Avoidance/monitoring of some drugs (e.g., diuretics, decongestants, antihistamines, antidepressants)
Timed or organized voiding (bladder retraining)
Pelvic floor exercises
Avoidance or treatment of constipation
Management of Moderate - Severe (IPSS > 8) BPH Include side effects.
Alpha-blockers: Side effects: H/A, dizziness, Orthostatic hypotension, retrograde ejaculation (ejaculation failure)
5-alpha reductase inhibitors: For larger prostates (eg. DRE>30mL or PSA>1.5 ng/dL), Side effects: Decreased libido, erectile dysfunction, ejaculatory disorder
Combo alpha blocker + 5 alpha reductase inhibitor if symptomatic LUTS + prostate enlargement (>30 cc). After 6-9 months of combination therapy, consider stopping alpha blocker
Also options of : antimuscarinics, beta 3 agonist (mirabegron), and anticholinergics
Management of LUTS + erectile dysfunction
PDE-5 inhibitors for LUT symptoms + erectile dysfunction
Management of Storage Symptoms. What do you add if voiding symptoms.
Antimuscarinics and beta 3 agonists caution if obstruction or PVR >250mL. Use in combination with alpha blocker if voiding + storage symptoms.
Management of nocturnal polyuria
Desmopressin
Indications for surgery
Recurrent or refractory urinary retention
Recurrent UTI
Bladder Stones
Recurrent hematuria
Renal dysfunction secondary to BPH
If medical management fails
Preoperative testing
Cystoscopy +/- transrectal or transabdominal U/S
List 2 types of surgeries. List indications and the ADRs.
Monopolar – Transurethral resection of the prostate (M-TURP)
Moderate to severe LUTS due to BPH in pts with prostate volume 30-80 cc
ADRS: Retrograde ejaculation (65%), ED (6.5%), urinary retention (4-13%), hematuria, TUR syndrome, infection, incontinence
Prostatectomy (open simple vs. laser)
Can be used for prostates > 80cc
