BPH

Question 1

What are the 4 zones of the prostate?

Answer 1

peripheral
central
transitional
anterior

Question 2

What is the MC zone to develop prostate cancer?

Answer 2

peripheral zone

Question 3

What is the MC zone to develop BPH?

Answer 3

transitional zone

Question 4

What is the MC zone to develop prostatitis?

Answer 4

central zone

Question 5

What are the 3 types of tissue in the prostate gland?

Answer 5

epithelial tissue
stromal tissue
capsule

Question 6

What is the main function of the epithelial tissue?

What stimulates the epithelial tissue?

Answer 6

produce prostatic secretions

androgens

Question 7

What is the primary receptor in the stromal tissue?

What stimulates the stromal tissue?

Answer 7

alpha 1 adrenergic receptors
(also seen in the capsule)

norepinephrine
(NE –> smooth muscle contraction –> extrinsic compression of the urethra –> dec bladder emptying)

Question 8

What is the normal ratio of stromal to epithelial tissue?

Answer 8

2:1 (stromal:epithelial)

Question 9

What is the ratio of stromal to epithelial tissue in BPH?

Answer 9

5:1 (stromal:epithelial)

Question 10

Where is type 1 5alpha reductase located?

What does DHT cause in these locations?

Answer 10

sebaceous glands in the frontal scalp, liver, skin

causes acne, inc body/facial hair

Question 11

Where is type 2 5alpha reductase located?

What does DHT cause in these locations?

Answer 11

prostate, genital tissue, hair follicles of scalp

induces growth and enlargement of the gland

Question 12

In the pathogenesis of BPH, what do STATIC factors relate to?

Answer 12

enlargement of the prostate gland

depends on:

• androgens stimulating the epithelial tissue
• estrogens stimulating the stromal tissue

Question 13

In the pathogenesis of BPH, what do DYNAMIC factors relate to?

Answer 13

excessive alpha adrenergic tone on the stromal tissue

results in contraction of the gland around the urethra

Question 14

What are other factors implicated in the pathophysiology of BPH?

Answer 14

chronic prostatic inflammation
advanced atherosclerosis
dec release of nitric oxide
dec production of cGMP

Question 15

What are other factors implicated in the pathophysiology of BPH?

Answer 15

chronic prostatic inflammation
advanced atherosclerosis
dec release of nitric oxide
dec production of cGMP

Question 16

What are signs and symptoms of OBSTRUCTIVE vs IRRITATIVE BPH?

Answer 16

OBSTRUCTIVE:

• urinary hesitancy
• urine dribbling
• bladder fullness post voiding

IRRITATIVE:

• urinary frequency
• urinary urgency
• nocturia

Question 17

What PSA level indicates an enlarged prostate?

Answer 17

1.4 ng/mL

Question 18

How is mild asymptomatic/mildly bothersome BPH w/ no complications managed?

Answer 18

watchful waiting
behavior modification
12 month return visits

Question 19

How is BPH w/ moderate or severe symptoms managed?

Answer 19

drug therapy or surgery

Question 20

What are the 3 types of agents used in BPH drug therapy?

Answer 20

• agents that interfere w/ testosterone’s stimulatory effect on prostate gland enlargement
• agents that relax prostatic smooth muscle
• agents that relax bladder detrusor muscle

Question 21

What are the non selective alpha 1 adrenergic antagonists?

Which factor do they target?

Answer 21

Doxazosin (immediate release)
Terazosin (immediate release)
Alfuzosin (extended release – less CV ADEs)
Prazosin

dynamic

Question 22

What are the selective alpha 1 adrenergic antagonists?

Which factor do they target?

Answer 22

Tamsulosin
Silodosin

dynamic

Question 23

Tadalafil

• MOA
• class
• which factor does it target?

Answer 23

causes smooth muscle relaxation (prostate, bladder neck, prostatic urethra)

PDE 5

dynamic

Question 24

What precautions need to be considered with immediate release terazosin and doxazosin?

Answer 24

slow titration to minimize orthostatic hypotension and first dose syncope

solution: long acting formulation of doxazosin

Question 25

Finasteride: - MOA - which factor does it target?

Answer 25

blocks 5alpha reductase enzyme static

Question 26

Bicalutamide, Flutamide: - MOA - which factor does it target?

Answer 26

blocks DHT at intracellular receptor static **not FDA approved for BPH -- used for prostate cancer

Question 27

Leuprolide, Goserelin: - MOA - which factor does it target?

Answer 27

blocks pituitary release of LH static **not FDA approved for BPH -- used for prostate cancer

Question 28

Megestrol Acetate: - MOA - which factor does it target?

Answer 28

blocks pituitary release of LH and blocks androgen receptor static **not FDA approved for BPH -- used for prostate cancer

Question 29

Oxybutynin, Mirabegron: MOA

Answer 29

relax detrusor muscle of bladder

Question 30

What is the role of alpha1 adrenergic antagonist in BPH drug therapy?

Answer 30

interim measure relieves voiding symptoms

Question 31

At what size of the prostate are 5 alpha reductase inhibitors indicated? What is their role in BPH drug therapy?

Answer 31

at least 40g - delay symptom progression - reduce complications - dec gland size by ~25%

Question 32

Among all alpha 1 adrenergic antagonists, what are their similarities and differences?

Answer 32

equally effective differ in cardiovascular effects

Question 33

What are the ADE's associated with Terazosin and Doxazosin?

Answer 33

first dose syncope orthostatic hypotension dizziness

Question 34

Which of the alpha 1 adrenergic antagonists is the gold standard? Why?

Answer 34

Tamsulosin selectivity, less CV effects **NOT more effective **

Question 35

What is a major disadvantage of 5 alpha reductase inhibitors?

Answer 35

slow onset of action (takes up to 6 months to exert maximal effects)

Question 36

5 Alpha Reductase Inhibitors: ADEs

Answer 36

GYNECOMASTIA dec libido erectile dysfunction ejaculation disorders

Question 37

Alpha Adrenergic Antagonists: ADEs

Answer 37

``` FLOPPY IRIS SYNDROME syncope lightheadedness orthostatic hypotension tachycardia nasal congestion ejaculatory dysfunction priapism ```

Question 38

Alpha Adrenergic Antagonists: monitoring parameters

Answer 38

BP | HR

Question 39

Alpha Adrenergic Antagonists: patient education

Answer 39

start at lowest dose - slow titration up first dose at bedtime caution w/ cataract surgery seek medical attention if painful erection lasting longer than 4 hrs

Question 40

5 Alpha Reductase Inhibitors: monitoring parameter

Answer 40

PSA (should dec by 50%)

Question 41

Which agents relax prostatic smooth muscle?

Answer 41

alpha 1 adrenergic antagonists phosphodiesterase inhibitors

Question 42

Which agent decreases prostate size?

Answer 42

5 alpha reductase inhibitors

Question 43

Which agent decreases PSA?

Answer 43

5 alpha reductase inhibitors

Question 44

Which agent has NO cardiovascular effects?

Answer 44

5 alpha reductase inhibitors

Question 45

Which agents exclusively treats irritative symptoms?

Answer 45

anticholinergic agents mirabegron (no efficacy in relieving bladder outlet obstruction)

Question 46

Which agent has no sexual dysfunction ADEs?

Answer 46

phosphodiesterase inhibitors

Question 47

Mirabegron: MOA

Answer 47

beta 3 adrenergic receptors inc production of cAMP --> relaxed detrusor muscle --> reduced irritative/voiding symptoms, inc bladder capacity, inc interval bt voidings

Question 48

Mirabegron: monitoring parameters

Answer 48

BP | bowel habits

Question 49

Mirabegron: class

Answer 49

beta 3 adrenergic agonist

Question 50

Mirabegron: ADEs

Answer 50

dose related, reversible ``` HYPERTENSION IMPAIRED COGNITION tachycardia dry mouth nausea constipation diarrhea headache nasopharyngitis ```

Question 51

What are the surgical options for BPH? | What are their indications?

Answer 51

``` TURP (biopsy possible) green light (no biopsy possible) ``` INDICATIONS: - moderate-severe symptoms - no response/don't tolerate drug therapy - BPH w/ complications