Benign Prostate Disorders

Question 1

Sexual accessory glands

Answer 1

○ Prostate
○ Seminal vesicles
○ Vas Deferens
○ Bulbourethral gland

Question 2

Principle function of the prostate and
related accessory organs is ______

Answer 2

production of the various components of semen for sexual reproduction.

Question 3

Prostate - Most Common Disorders

Answer 3

★ Prostatitis
★ Benign Prostate Hyperplasia
★ Prostate Adenocarcinoma
(included in the neoplasm lecture)

Question 4

Prostatitis

Answer 4

● Bacterial infection in the small ductwork of the prostate gland
○ Typical uropathogens: E. Coli, Klebsiella, Enterococcus, etc
○ Rarely can be from Gonorrhea / Chlamyida

Question 5

Prostatitis - Pathophysiology

Answer 5

● Typically interstitial, affecting the whole gland
● Rarely presents as focal abscess
● Poorly defined or understood chronic pain / Inflammatory issues often grouped
as chronic prostatitis

Question 6

Prostatitis - Clinical Presentation

Answer 6

● Clinical diagnosis primarily
● Perineal / pelvic pain
○ May radiate to the rectum, scrotum, groin, sacrum, lower back
● Obstructive voiding symptoms
○ Weak stream, hesitancy, intermittent stream, feeling of incomplete emptying, terminal dribbling, dysuria
● Constitutional symptoms (fever, chills, nausea, vomiting) may occur

Question 7

Prostatitis - Acute vs. Chronic

Answer 7

● Acute Bacterial
○ Typical presentation, often developing rapidly and severely
○ Tender, boggy prostate on DRE
○ Often find leukocytosis on UA, but not always. Urine culture may or may not be positive
● Chronic (>3 months)
○ Can be hard to clearly identify as
bacterial or inflammatory
○ Typical presentation, but gradual onset
and muted / poorly defined symptoms
○ Commonly will have normal DRE, UA
and urine culture

Question 8

Prostatitis - Management for Acute bacterial prostatitis

Answer 8

○ Poor tissue penetrance of antibiotics in the prostate for most medications
○ Suspected STI, treat according to CDC guidelines for urethritis but consider a prolonged
course to allow for full clearance due to typical bacterial response in the prostate
○ Most of the time, uropathogens will clear with sulfamethoxazole-trimethoprim DS or
fluoroquinolones (ciprofloxacin 500 mg BID or levofloxacin 500-750 mg daily)
○ Duration of treatment is typically 10-14 days, depending on severity of symptoms
○ Alpha-blockers (tamsulosin, alfuzosin, etc) are a consideration to help obstructive LUTS
○ Phenazopyridine can help with dysuria symptoms

Question 9

Prostatitis - Management of Chronic bacterial prostatitis

Answer 9

○ Similar treatment guidelines as Acute, but needs longer courses
○ Can take 4-12 weeks to resolve
○ May need catheterization if related retention
○ Often needs evaluation with Urology for cystoscopy
● Careful using FQ abx for extended
periods of time due to risk of
tendinitis and tendon rupture

Question 10

Prostatitis - Complications

Answer 10

● Prostate abscess
● Urinary retention
● Urosepsis

Question 11

BPH - Etiology

Answer 11

● Abnormal growth of prostate after adulthood
● Exclusively a disease of older men
● Unclear exact cause, but several theories
○ Some evidence of alterations to the androgen receptors
in the prostate with age
○ Some evidence of alterations to the apoptotic response
of prostate cells
○ Some evidence of increased sensitivity to the DHT (dihydrotestosterone) receptors in prostate cells,

Question 12

BPH - Patient History

Answer 12

● Classic symptoms are obstructive LUTS
○ Weak urine stream, hesitancy, straining to void,
intermittent stream, incomplete emptying,
post void dribbling
● Can also include irritative LUTS
○ Frequency, urgency, urge incontinence (UUI),
nocturia, infrequently dysuria
● May have gross hematuria, but not often
● Usually symptoms develop over time

Question 13

International Prostate
Symptom Score (I-PSS)

Answer 13

Standardized, validated
questionnaire used as frequent
primary endpoint in studies of all
medications / procedures for BPH

Question 14

BPH - Pathophysiology

Answer 14

Frequency (often associated with urgency and/or UUI) has three main
causes:
○ Bladder empties and fills rapidly (polyuria)
○ Bladder doesn’t hold much anyway (OAB)
○ Bladder doesn’t completely empty
(incomplete bladder emptying)

Question 15

BPH - Physical Exam / Labs / Imaging

Answer 15

● Not much initial exam necessary, aside from DRE
● Urinalysis (dip or micro) to check for bloody urine
● PSA should be included, especially if
risk factors / age indicate screening anyway
● Bladder scan for post void residual (PVR)
may be helpful if convenient
● Consider BMP to check renal function

Question 16

BPH - Urology Workup

Answer 16

● DRE / UA / PSA if not already done previously
● Post void residual (PVR)
● Cystoscopy
● Uroflow / Urodynamics

Question 17

BPH - Treatment (BPH Meds)

Answer 17

● Alpha blockers
● 5-⍶ reductase inhibitors (5-aRI) [2nd line]

Question 18

Side Effects of Alpha blockers

Answer 18

Orthostatic hypotension, headache,
retrograde ejaculation

Question 19

Alpha blockers

Answer 19

○ First generation: prazosin
■ Never developed as a BPH treatment, just for HTN
○ Second generation: terazosin, doxazosin
■ Not preferred for first-line BPH treatment due to high risk of hypotension
■ Requires titration to reach therapeutic effect and avoid hypotensive side effects
○ Third generation: Tamsulosin 0.4 mg daily, alfuzosin 10 mg daily, silodosin 8 mg daily
■ Most common first-line treatment due to mix of safety, efficacy, affordability

Question 20

Alpha blockers MOA

Answer 20

○ Causes relaxation of the smooth muscles of the prostatic urethra, increasing the radius of the prostate lumen, thereby increasing flow

Question 21

Conservative Measures for BPH - Treatment (for irritative LUTS)

Answer 21

○ Fluid restriction for nocturia
○ Bladder training

Question 22

BPH - Treatment (for irritative LUTS)

Answer 22

● Conservative Measures
○ Fluid restriction for nocturia
○ Bladder training
● Anticholinergics
○ Blocks ACh binding to muscarinic receptors in detrusor muscle
○ Oxybutynin, tolterodine, trospium, darifenacin,
solifenacin, fesoterodine
● Beta-3 Agonists
○ Stimulates beta-3 receptors in the sympathetic nerve pathway to relax detrusor
○ (Only brand name currently) mirabegron, vibegron

Question 23

BPH - Treatment (Complementary / Alternative Med)

Answer 23

● Supplements
○ Beta-sitosterol: cholesterol-like plant compound
○ Studies suggesting improvement of IPSS, urine flow rates, decreased residual volumes
○ Some may recommend, not part of any treatment guidelines due to incomplete efficacy
and safety studies
● Herbals / Nutraceuticals
○ Saw palmetto, Pygeum africanum, stinging nettle(!), zinc, selenium
○ Most studies lack power: single center, short duration,
problems with placebo choice or lack of, unconventional
endpoints, responder analysis only, etc.
○ Most reported efficacy is based on (at best) expert opinion /
case series or (at worst) anecdotal evidence

Question 24

BPH - Treatment (Surgery)

Answer 24

● TURP
● “Minimally Invasive Procedures”
○ Prostatic Urethral Lift (UroLift)
○ Water Vapor Thermal Therapy (Rezum)
● Prostate enucleation
○ Simple Prostatectomy
○ Laser Enucleation (HoLEP or ThuLEP)
● Emerging techniques
○ Robotic Waterjet Treatment (Aquablation)
○ Prostate Artery Embolization (PAE)
○ Temporary Implanted Prostatic Devices

Question 25

BPH - TURP

Answer 25

● Transurethral approach under general anesthesia: single site, no incision
● Loop for resection, bipolar button for vaporization, incision with button or
loop, or laser for “photoselective vaporization”
● Same-day surgery, catheter time 1-3 days

Question 26

BPH - “Minimally Invasive Procedures”

Answer 26

● Done in office or OR with or without
general anesthesia
● Pros: Lower rates of ejaculatory dysfunction, no general anesthesia
● Cons: Typically less effective, shorter time to additional intervention (5 yr)
● Prostatic Urethral Lift (UroLift)
● Water Vapor Thermal Therapy (Rezum)

Question 27

BPH - Prostate Enucleation

Answer 27

● Laser enucleation
○ HoLEP / ThuLEP (Holmium / Thulium)
○ End-firing laser to resect large prostate
○ Usually >100 ML prostate size
○ Same day, possibly overnight
○ More bleeding than other options possible
● Robotic / Open Simple Prostatectomy
○ Usually 5 lap ports, using surgical robot assistance
○ Bladder opened and prostate resected away from capsule
○ Similar indications for size, similar recovery and complications
○ Catheter time longer for enucleation (up to a week)

Question 28

non-surgical, emerging techniques for BPH

Answer 28

○ Robotic Waterjet Treatment (Aquablation)
○ Prostate Artery Embolization (PAE)
○ Temporary Implanted Prostatic Devices