Benign Prostate Hyperplasia (BPH)

Question 1

What is the function of the prostate?

Answer 1

Contributes for about 25% of ejaculate

Question 2

What does the prostate contribute to the ejaculate?

Answer 2

Citric acid
G proteolytic enzymes - eg. prostate specific antigen (PSA)
G seminal plasmin

Question 3

What is citric acid used for?

Answer 3

Provides sperm with energy

Question 4

What is PSA used for?

Answer 4

Help facilitate sperm motility via liquefaction of seminal fluid
Dissolving cervical mucus

Question 5

What is G seminal plasmin used for?

Answer 5

Sperm motility
Potent antimicrobial activity

Question 6

What is PSA?

Answer 6

Glycoprotein enzyme secreted by epithelial membranes of prostate cells

Question 7

What happens to PSA with age?

Answer 7

Increases
Also increases with size of prostate

Question 8

Why does the prostate tend to get bigger with age?

Answer 8

Age
Tissue remodelling
Hormonal effects
Metabolic effects
Inflammation

Question 9

What happens with age?

Answer 9

Larger prostate + lower flow of rates of urine

Question 10

How does tissue remodelling increase the prostate?

Answer 10

The balance between cell growth + apoptosis is disrupted

Question 11

How does hormonal effects increase the prostate?

Answer 11

Androgen is the main regulator in stimulating proliferation + inhibiting apoptosis

Question 12

How does inflammation increase the prostate?

Answer 12

Inflammation within prostate triggers cytokine release + resultant healing responses = proliferative environment dominant

Question 13

What are the symptoms?

Answer 13

Lower tract urinary symptoms (LUTS)
Voiding symptoms
Storage symptoms
Acute/chronic urinary retention

Question 14

What are voiding symptoms?

Answer 14

Hesitancy associated with resistance to urinary flow
Poor urinary flow = increased time to urinate
Incomplete bladder emptying = increased times at toilet

Question 15

What are storage symptoms?

Answer 15

Urgency
Polyuria during day + night

Question 16

What can cause an acute/chronic urinary retention to develop?

Answer 16

Bladder outflow obstruction
Very painful
= chronic UTI

Question 17

How do you diagnose?

Answer 17

International prostate symptom score (IPSS)
Medical + drug history
Physical examination = bladder + rectal
Urine dipstick test
Complete urine frequency chart
Assessment of serum creatine if renal impairment suspected

Question 18

What are the scores for IPSS?

Answer 18

0-7 = mild
8-19 = moderate
20-35 = severe

Question 19

What is the focus of treatment?

Answer 19

Control LUTS
Minimise impact on QoL
Reduce other issues - eg. hospital admission + recurrent UTI

Question 20

What can be lifestyle issues?

Answer 20

Not adequate fluid intake
Drinking large amounts of fluids
Medication on symptoms
Food + drinks containing active substances

Question 21

What is the pharmacological management?

Answer 21

Reduce smooth muscle tone
Alter size of prostate

Question 22

What are the first drugs used?

Answer 22

Alpha blockers

Question 23

Where does alpha-1 + alpha-2 receptors exist?

Answer 23

Both in bladder
Alpha-2 in CVS

Question 24

What are examples of alpha blockers?

Answer 24

Tamsulosin
Doxazosin
Alfuzosin
Terazosin

Question 25

What does alpha blockers do?

Answer 25

Improve IPSS = improve urinary flow BUT do NOT alter prostate size

Question 26

What is the problem with alpha blockers?

Answer 26

Older agents cause more cardiovascular problems = first dose hypotension = taken at night

Question 27

What are the adverse effects of alpha blockers?

Answer 27

Postural hypotension Headache Dizziness Drowsiness Sweating

Question 28

What are some adverse effects of alpha blockers caused by?

Answer 28

Initial doses = first doses taken bedtime = patient lying down

Question 29

Who is Tamsulosin OTC licensed for?

Answer 29

Men aged 45-75 years

Question 30

What is the dose of Tamsulosin OTC?

Answer 30

400 microgram dosage units

Question 31

How long can Tamsulosin OTC be taken for?

Answer 31

6 weeks before clinical assessment by doctor

Question 32

When should a patient see a doctor when using Tamsulosin OTC?

Answer 32

After 14 days if symptoms have not improved

Question 33

What is the second drug?

Answer 33

5-alpha reductase inhibitors (5ARIs)

Question 34

What does 5ARIs do?

Answer 34

Stop the conversion of testosterone to dihydrotestosterone (DHT)

Question 35

How does 5ARIs benefit?

Answer 35

Improve IPSS Reduce PSA Reduce likelihood of requiring surgery Reduce prostate volume

Question 36

What does Dutasteride inhibit? 5ARI

Answer 36

I + II

Question 37

What does Finasteride inhibit?

Answer 37

II

Question 38

What are the adverse effects of 5ARIs?

Answer 38

Loss of libido Impotence Ejaculatory dysfunction Breast tenderness

Question 39

What is the problem with 5ARIs?

Answer 39

Drug is present in sperm + women of child bearing age should NOT be exposed to it Either through intercourse or handling broken tablets

Question 40

Why combine the treatment?

Answer 40

Reduce progression Improve symptom score Improve LUTS Improve prostate size

Question 41

Who is the combined treatment for?

Answer 41

Men with worsening LUTS + large prostates Estimated over 30g

Question 42

What are the surgical interventions?

Answer 42

Transurethral resection of prostate (TURP) Transurethral incision of prostate (TUIP) Laser prostatectomy