BPH

Question 1

Obstructive s/s of BPH?

Answer 1

urinary hesitancy
urine dribbling
bladder fullness post voiding

Question 2

Irritative s/s of BPH?

Answer 2

result from long-standing obstruction at the bladder neck

urinary frequency

urgency

nocturia

Question 3

Complications of BPH progression?

Answer 3

chronic kidney disease

gross hematuria

urinary incontinence

recurrent UTI

bladder diverticula

bladder stones

Question 4

Normal prostate size?

Answer 4

2 x 3 x 4 cm

weighs ~ 20g

Question 5

What are the 3 types of tissue in the prostate?

Answer 5

epithelial tissue (aka glandular)

stromal (aka smooth muscle)

capsule

Question 6

What stimulates epithelial tissue growth?

Answer 6

androgens

Question 7

Stromal tissue and the capsule is embedded with….

Answer 7

alpha 1 adrenergic receptors

-norepinephrine causes smooth muscle contraction and capsule contraction around the urethra

Question 8

What is the principal testicular androgen?

What is the principal adrenal androgen?

Answer 8

testosterone

Androstenedione

Question 9

Testosterone and Androstenedione are responsible for….

Answer 9

penile and scrotal enlargement

increased muscle mass

maintenance of the normal male libido

Question 10

Testosterone and Androstenedione are converted by…. in target cells to….

Answer 10

5 alpha reductase

dihydrotestosterone (DHT), an active metabolite

Question 11

Which is a more potent androgen in the prostate, DHT or testosterone?

Answer 11

DHT

Question 12

What does DHT do in the prostate?

Answer 12

induces growth and enlargement of the gland

Question 13

What drug class can help to reduce enlarged prostate gland (epithelial tissue)?

Answer 13

5 alpha reductase inhibitors

Question 14

What drug class can help with sxs due to problem with stromal tissue?

Answer 14

alpha1-adrenergic antagonists are quickly effective in symptomatic management of urinary flow

Question 15

BPH sxs may be exacerbated by which drug classes?

Answer 15

anticholinergic agents
antihistamines
tricyclic antidepressants
phenothiazines

Question 16

Goals of BPH management?

Answer 16

control sxs

prevent progression of complications

delay need for surgical intervention

Question 17

Tx for moderate/severe sxs BPH?

Answer 17

drug therapy or surgery

Question 18

Sxs of BPH usually result from both…

Answer 18

static and dynamic factors

Question 19

Which drugs can help to reduce dynamic factors?

Answer 19

Blocks alpha adrenergic receptors in prostatic stromal tissue: Prazosin, Doxazosin, Terazosin

Blocks alpha receptors in the prostate: tamsulosin

Causes smooth muscle relaxation: Tadalafil

Question 20

What are the 2 types of 5alpha reductase?

Answer 20

Type I- localized to sebaceous glands in frontal scalp, liver and skin > causes acne and increased body and facial hair

Type II- localized to the prostate, genital tissue, and hair follicles of the scalp > induces growth and enlargement of the gland

Question 21

What ratio is exaggerated in BPH?

Answer 21

stromal-to-epithelial tissue ratio of 5:1

normal is 2:1

Question 22

What drug class can help with sxs due to problem with stromal tissue?

Answer 22

alpha1-adrenergic antagonists are quickly effective in symptomatic management of urinary flow

Question 23

What are static factors involved in BPH?

Answer 23

anatomic enlargement of the prostate gland

> depends on androgen stimulation of epithelial tissue and estrogen stimulation of stromal tissue in the prostate

Question 24

What are dynamic factors involved in BPH?

Answer 24

excessive alpha-adrenergic tone of the stromal component of the prostate gland

> results in contraction of the prostate gland around the urethra and narrowing of the urethral lumen

Question 25

What are the 3 categories of drug therapies for BPH?

Answer 25

- Agents that interfere with testosterone's stimulatory effect on prostate gland enlargement (static) - agents that relax prostatic smooth muscle (dynamic) - agents that relax bladder detrusor muscle (improves urine storage capacity)

Question 26

Which drugs can help to reduce dynamic factors?

Answer 26

Doxazosin, Terazosin, Prazosin, etc. Tamsulosin Tadalafil

Question 27

What are the two ways to dose IR Terazosin and Doxazosin?

Answer 27

Schedule 1: slow titration Schedule 2: quicker titration (slow to minimize orthostatic hypotension)

Question 28

What mechanisms reduce static factor?

Answer 28

blocks 5 alpha reductase enzyme (Finasteride) Blocks diihydrosterone at its IC receptor blocks pituitary release of LH blocks pituitary release of LH and blocks androgen receptor

Question 29

MOA of Oxybutynin and Mirabegron?

Answer 29

relaxes detrusor muscle of bladder

Question 30

Role of alpha 1 adrenergic antagonist?

Answer 30

relieves voiding sxs

Question 31

Older second-generation immediate-release formulations(e.g., terazosin, doxazosin) can cause...

Answer 31

adverse CV effects: 1st dose syncope, orthostatic hypotension, dizziness

Question 32

Name 2 3rd generations alpha 1 adrenergic antagonists

Answer 32

Tamulosin, Silodosin Uroselective agents, good alternatives

Question 33

Which patients are 5 alpha reductase inhibitors good for?

Answer 33

for pts with large prostates who wish to avoid surg and can't tolerate the side effects of alpha1 adrenergic antagonists

Question 34

Disadvantage of 5 alpha reductase inhibitors?

Answer 34

SLOW ONSET, taking up to 6 months for maximal effects

Question 35

What should you monitor in pts taking alpha adrenergic antagonists?

Answer 35

BP, HR

Question 36

ADEs of alpha adrenergic antagonists?

Answer 36

floppy iris syndrome, priapism, syncope, lightheadedness, orthostatic hypotension, nasal congestion

Question 37

What should you monitor in a pt taking 5 alpha reductase inhibitors?

Answer 37

PSA | should decrease by 50% iif adherent to therapy(

Question 38

ADEs of 5 alpha reductase inhibitors?

Answer 38

Erectile dysfunction Decreased libido Ejaculatory dysfunction Gynecomastia

Question 39

What should you use if you need to fix BPH immediately? What if sxs are just mild and prostate is enlarging slowly?

Answer 39

alpha1 adrenergic antagonists 5 alpha reductase inhibitors

Question 40

ADEs of phosphodiesterase inhibitors?

Answer 40

``` Headache Dizziness Nasal congestion Dyspepsia Back pain Myalgia Hearing loss ```

Question 41

What side effect would make you want to discontinue Tadalafil?

Answer 41

hearing loss

Question 42

Name a beta3 adrenergic agonists. What does it do?

Answer 42

Mirabegron release cAMP, which relazes the detrusor muscle --> reducing the irritative voiding sxs (increased urinary bladder capacity)

Question 43

ADE of Mirabegron?

Answer 43

HTN impaired cognition others: tachycardia, dry mouth, nausea, constipation, HA

Question 44

Surgical option for BPH?

Answer 44

for pts with severe sxs who don't respond to or don't tolerate meds TURP (Bx possible) Green Light (no bx possible)

Question 45

Tx for mild sxs?

Answer 45

watchful waiting

Question 46

Tx for moderate sxs with ED?

Answer 46

alpha-adrenergic antagonist phosphodiesterase inhibitor or BOTH

Question 47

Tx for moderate sxs with small prostate and low PSA?

Answer 47

alpha-adrenergic antagonist

Question 48

Tx for moderate sxs with large prostate and increased PSA?

Answer 48

5 alpha reductase inhibitor + alpha-adrenergic antagonist

Question 49

Tx for moderate sxs predominant irritative voiding sxs?

Answer 49

alpha-adrenergic antagonist + anticholinergic agent OR alpha-adrenergic antagonist + Mirabegron

Question 50

Tx for severe sxs with complications?

Answer 50

minimally invasive surg or prostectomy?

Question 51

Which decreased prostate size; alpha1 adrenergic antagonists or 5alpha reductase inhibitors?

Answer 51

5 alpha reductase inhibitors

Question 52

Which relaxes prostatic smooth muscle; alpha1 adrenergic antagonists or 5alpha reductase inhibitors?

Answer 52

alpha 1 adrenergic antagonists

Question 53

which halts disease progression; alpha1 adrenergic antagonists or 5alpha reductase inhibitors?

Answer 53

5 alpha reductase inhibitors

Question 54

which has CV adverse effects; alpha1 adrenergic antagonists or 5alpha reductase inhibitors?

Answer 54

alpha 1 adrenergic antagonists