BPH

Question 1

define BPH

Answer 1

Condition when prostate gland enlarges enough to compress the urethra and cause urinary obstruction

Question 2

What causes lower urinary tract symptoms in BPH?

Answer 2

gland enlargement and increased smooth muscle tone

Question 3

How evident is BPH in men at 50? at 80?

Answer 3

Clinically evident in 50% of men by age 50, in 90% by age 80

Question 4

What is BPH characterized by?

Answer 4

Characterized by uncontrolled growth in deep mucosal glands of prostate and by proliferation of nearby stromal cells

May be due to androgens

Question 5

What are the rsk factors for BPH?

Answer 5

Genetics

Black males

Question 6

What is the pathophysiology of BPH?

Answer 6

1. As men age, an androgen-estrogen imbalance occurs
   Androgen production decreases while estrogen production increases
   -The above combination is felt to stimulate prostatic growth
   -Cellular overgrowth begins in transition zone
2. High levels of dihydrotestosterone:
   Main prostatic intracellular androgen

Question 7

Where does BPH usually start?

Answer 7

!. transition zone

Question 8

What is 5-alpha reductase and why is it important?

Answer 8

Converts testosterone to more potent dihydrotestosterone

Promotes stromal and basal prostate cell growth

Question 9

How is blood flow and urine affected by BPH?

Answer 9

Growth of tissue causes areas of poor blood flow and tissue damage (necrosis)

Prostate hypertrophy
Decreases urine flow by distorting or compressing urethra

Question 10

What are some complications of BPH?

Answer 10

1. Urinary obstruction
   - Main complication
   - Can lead to UTI or calculi
2. Incontinence
3. Urethral stenosis
4. Hydronephrosis
5. Acute or chronic renal failure

Question 11

What are the obstructive symptoms in BPH?

Answer 11

Reduced urinary stream caliber and force
Hesitancy
Feeling of incomplete emptying
Double voiding (repeat < 2 hr)
Post-void dribbling
Straining to void

Question 12

What are the irritative symptoms in BPH?

Answer 12

Urgency
Nocturia
Frequency

Question 13

What are the abdominal signs of BPH?

Answer 13

Assess for distended bladder

Question 14

What are the normal digital rectal exam signs?

Answer 14

Prostate smooth 
Firm 
Enlarged 
Nontender 
No masses

Question 15

Why are UA and urine C&S performed in BPH?

Answer 15

R/O UTI

Question 16

When should CT abd/pelvis or renal us be performed?

Answer 16

If complicates suspected

Question 17

Digital rectal exam affects PSA in what way

Answer 17

Transiently elevated

Question 18

Why are alpha 1 blockers used in BPH? What are some examples?

Answer 18

Reduces smooth muscle tone in bladder neck, prostate, & arteries

Prazosin/Minipress 
Terazosin/Hytrin 
Doxazosin/Cardura
Siladosin/Rapaflo
Alfuzosin/Uroxatral

Question 19

What do you have to be careful about when using alpha 1 blockers?

Answer 19

Be careful of “first dose effect” with these drugs
First dose may produce an exaggerated hypotensive causing syncope
Dose low & slowly titrate up or give at hs

Question 20

Why are alpha 1-a adrenergic receptor antagonists used in BPH? What is an example?

Answer 20

Tamsulosin/Flomax
Relaxes smooth muscle in bladder neck & prostate only

Fewer systemic side effects than alpha 1 antagonists

Question 21

Why are 5 alpha reductase inhibitors used in BPH?

What are 2 examples?

Answer 21

1. Antiandrogen effect
   A. Finasteride/Proscar (Propecia)
   B. Dutasteride/Avodart
2. Blocks conversion of testosterone to dihydrotestosterone
3. Results in ~20% reduction in prostate size
4. Lowers PSA (Need baseline)

Question 22

What are the SE of 5 alpha reductase inhibitors used in BPH?

Answer 22

Impotence
Decreased libido
Decreased ejaculate volume
Depression or anxiety
Gynecomastia

Question 23

What is phytotherapy and what are some examples?

Answer 23

Use of plant extracts for medicinal purposes: 
Saw palmetto
Echinacea 
Soy 
Red Clover

Question 24

What are some ‘other’ medications used for BPH?

Answer 24

Tadalafil /Cialis

Dutasteride + tamsulosin / Jalyn

Question 25

What the percentages of the various BPH treatments?

Answer 25

1. Watchful waiting: 4% 2. TURP/TUIP: 62% 3. Open prostatectomy: 1% 4. Green light laser ablation (PVP): 22% 5. TUMT: 5% 6. TUNA: 3% 7. Other: 3%

Question 26

Describe a TURP

Answer 26

1. Transurethral Resection of the prostate 2. Performed under spinal anesthesia by a Urologist 3. Resectoscope removes the prostate tissue to create a larger channel for the patient to urinate 4. 1 hour surgery and pt usually needs to stay 1-3 days 5. Continuous irrigating catheter post-op 6. Risk of retrograde ejaculation, ED 7. Full recovery 4-6 wks

Question 27

Describe a TUIP

Answer 27

1. Transurethral Incision of Prostate 2. Widens the urethra by making small cuts in the prostate at bladder neck, rather than removing prostate tissue 3. Used for mild-moderate BPH 4. Less morbidity than TURP 5. Shorter procedure 6. Faster recovery - 1 day surgery 7. Less risk of retrograde ejaculation 8. Risk of urinary retention 9. May need repeat procedure

Question 28

Describe Laser therapy

Answer 28

1. Transurethral laser induced prostatectomy (TULIP) 2. Performed under transrectal ultrasound guidance: Laser instrument placed in urethra and transrectal U/S directs the device as it is slowly pulled from bladder neck to apex 3. No immediate visual change, coagulation necrosis Tissue sloughs up to 4. 3 mo, long term catheter

Question 29

Describe PVP

Answer 29

1. Photovaporization of prostate (PVP) 2. OP procedure 3. High power laser surgery-vaporizes prostate tissue 4. Recovery 2-3 days 5. Immediate change seen similar to TURP 6. Urethral mucosa spared 7. Prostate tissue reabsorbed, not sloughed 8. Catheter < 24 hr 9. Risk of retrograde ejaculation

Question 30

Describe TUNA

Answer 30

1. Transurethral needle ablation of prostate (TUNA) 2. Specially designed urethral catheter is placed 3. Interstitial radiofrequency needles are deployed from tip of catheter  pierces prostatic urethra 4. Radiofrequencies heat tissue  coagulative necrosis 5. Bladder neck and median lobe enlargement not well treated by TUNA

Question 31

Describe TUMT

Answer 31

1. Minimally invasive 2. Local anesthesia in office 3. Microwave antenna within catheter emits microwaves to heat and destroy prostate tissue 4. Full recovery < 5 days 5. Foley catheter (or stent) left in place up to 2 weeks, edema expected 6. Preferred over TURP

Question 32

Describe Open Prostatectomy

Answer 32

1. Used when prostate too large (> 100 gm) to remove endoscopically 2. Approach can be: A. Suprapubic (transvesical) -Operation of choice if concomitant bladder pathology -Urethral and suprapubic catheter B. Retropubic -Bladder is not entered -Transverse incision is made in surgical capsule of prostate -Allows direct visualization of gland

Question 33

Describe pt education for BPH

Answer 33

1. Avoid antihistamines and anticholinergic medications 2. Fluid restriction to prevent bladder distension 3. Sitz baths after surgery 4. Take meds as directed 5. Catheter care