Benign Prostatic Hyperplasia Flashcards Preview

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Flashcards in Benign Prostatic Hyperplasia Deck (25)
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1

What is BPE?

Enlargment most commonly due to BPH.

 

2

What is BPH?

histological diagnosis and is characterised by non-cancerous hyperplasia of the glandular epithelial and stromal tissue of the prostate.

 

3

Why might you see LUTS in BPH?

Because BPH is the most common cause of Bladder Outlet Obstruction

However 15-30% of men over 65 have LUTS regardless of BPH

4

Pathophysiology

The exact mechanism is unknwon.

Androgens seem to play a role, particularly in the development of the gland in adolescence and then future development of BPH.

Prostate converts testosterone to dihydrotestostone DHT using the enzyme 5-alpha reductase.

DHT is more potent and accounts for 90% of androgen in the tissue.

The prostate retains the ability to respond to testosterone and thus levels of DHT also remain high throughout life.

5

Risk factors

Age

FH

Afro-Caribbean ethnicity

Obesity

6

Clinical features

LUTS with either voiding (hesitancy, weak strea, terminal dribbling or incomplete emptying) or storage (urinary frequency, nocturia, nocturnal enuresis or urge incontinence)

Other less common symptoms are haematuria and haematospermia

7

Examinations

DRE is essential especially to distinguish between BPH and prostate cancer

Firm, smooth and symmetrical prostate is a reassuring sign

International Prostate Symptom Score should be done as well IPSS

8

Explain IPSS

A screening tool used to evaluate and quantify LUTS

 

9

Dx

Prostate cancer - may present with LUTS but is usually asymmetrical, craggy/nodular prostate + raised PSA

UTI

Overactive bladder

Bladder cancer

10

Initial investigations

Urinary frequency and volume chart should also be done in LUTS

Bedside urinalysis to exclude UTI

Post-void bladder scan if there is any retention

PSA might be done if indicated from DRE, it can however be increased in BPH as well.

 

11

Imaging

USS-KUB might be done to calculate the volume of the prostate alongside assessment of the rest of the urinary tract for urinary retention and hydronephrosis.

Urodynamic studies can also show bladder contractility, flow rate and storage capacity. Bladder outlet obstruction index (BOOI) can help diagnose obstructive voiding related to BPH

12

On USS-KUB what is defined as an enlarged prostate?

>30ml 

13

Initial management

Since it is an incidental finding quite commonly patients just needs to be reassurd.

Ask patient to keep a symptom diary and provide a medication review

Give suitable lifestyle advice about moderate caffeine intake and alcohol intake.

14

Indications of medical management

Most men with symptomatic BPH

15

Medical management

First line is an alpha blocker like Tamsulosin
They act by relaxing the prostatic smooth muscle by blocking alpha-receptor leading to a reduction in the dynamic component.
They provide symptomatic benefit within a few days.

16

Side effects of tamsulosin

Postural hypotension

Retrograde ejaculation

Floppy-Iris Syndrome

17

What should be tried if the patient remains symptomatic despite alpha blocker?

5alpha-reductase inhibitors like Finasteride which prevent the conversion of testosterone to DHT leading to a decrease in prostatic volume.

Note that it can take up to 6 months to perceive any symptomatic benefit 

18

Indications of surgical management

Refractory through medical management or develop signficant sequale of BPH like high pressure retention

19

Surgical approaches

TURP (most commonly used=

Holmium laser enucleation of the prostate (HoLEP)

PVP

TUVP

TUMT

20

Explain TURP

This involves endoscopic removal of obstructive prostate tissue by using a diathermy loop to increase the urethral lumen size.

Complications include haemorrhage, sexual dysfunction, retrograde ejaculation and urethral strictures.

21

Explain HoLEP

Holmium:YAG laser is used to heat and dissect section of the prostate into the bladder.

It is becoming more popular due to excellent outcomes and reduced post-op complications

It is only used in a limited fashion due to it being a technically challenging procuedure

22

What is PVP, TUVP and TUMT?

PVP = Photoselective vaporisation of the Prostate

TUVP = Transurethral vaporisation of the prostate

TUMT = Transurethral microwave thermotherapy

 

 

23

Complications of BPH

High-pressure retention with chronic or acute-on-chornic urinary retention leading to post AKI

Recurrent UTI

Significant haematuria

TURP syndrome

24

What is TURP syndrome?

A rare but potentially life-threatening complication of TURP

TURP needs hypoosmolar irrigation during the procedure it can lead to significant fluid overload and hyponatraemia when the fluid enter the circulation through exposed venous beds.

25

Clinical features of TURP syndrome

Confusion

Nausea

Agitation

Visual changes

 

This needs urgent management by carefully reducing the level of hyponatraemia.