BPH

Question 1

Pathophys of BPH

Answer 1

• Prostate converts testosterone to dihydrotestosterone (DHT) using 5-alpha reductase
• DHT is more potent
• Prostate retains ability to respond to testosterone and so levels of DHT remain high through life

Question 2

RF BPH

Answer 2

• Older age
• FH - 1st degree
• Black african or Caribbean
• Obesity

Question 3

Symptoms of BPH

Answer 3

Voiding symptoms:
* Hesitancy
* Weak stream
* Terminal dribbling
* Incomplete empying

Storage symptoms:
* Frequency
* Nocturia
* Urge incontinence

Less common - haematuria, haematospermia

Question 4

Examination for BPH

Answer 4

• Smooth, firm symmetrical prostate
• More rounded and greater than 2 finger widths may indicate enlarged
• Patient should complete IPSS questionaire

International prostate symptom score - scoring LUTS

Question 5

Differentials for BPH

Answer 5

• Prostate cancer - craggy, nodular, asymmetric prostate on exam, raised PSA
• UTI - dysuria, loin or suprapubic pain, nitrite/leukocyte +ve dip
• OAB - storage LUTs dominate, good flow rate
• Bladder cancer - haematuria, LUTS less common

Question 6

Investigations for ?BPH bedisde and bloods

Answer 6

• Urinary frequency and volume chart - completed by patients
• Urinalysis - exclude UTI
• Post void bladder scan - assess for chronic retention

Question 7

When should PSA test be counselled for?

Answer 7

• Black African or Caribbean men 40yrs and older presenting with LUTS
• All other men over age of 50yrs presenting with LUTS

Question 8

Further investigations for BPH

Answer 8

• USS renal tract - calculate volume of prostate, assess for retention or hydronephrosis
• Urodynamic studies if diagnosis uncertain and concern re detrusor failure

Question 9

Management of BPH - monitoring and advice

Answer 9

• Reassure
• Symptom diary
• Medication review - cause of LUTs
• Lifestyle - avoid caffeine, reduce alcohol

Question 10

Medical management BPH

Answer 10

• Tamsulosin - alpha adrenorecpetor antagonist - relax smooth muscle, benefit within days
• If still symptomatic, Finasteride - 5-a reductase inhibitor but take up to 6 months for benefit, reduce prostatic volume
• ED - PDE5 inhibitors eg Sildenafil
• Anticholinergic if severe LUTS - avoid if retention

Question 11

Surgical management of BPH

Answer 11

• Used when refractory to medical management or develop complications of BPH eg high pressure retention
• Minimally invasive eg Steam treatment or Urolift to more invasive eg TURP, HOLEP

Question 12

How is TURP performed? What are some complications?

Answer 12

• Removal of obstructive prostate tissue using diathermy
• Increases luminal size
• Improvement within few months
• Complications: TURP syndrome, haemorrhage, sexual dysfunction, retrograde ejaculation, urethral stricture

Question 13

What is TURP syndrome?

Answer 13

• Rare but life threatening
• TURP requires the use of hypoosmolar irrigation during procedure if using monopolar energy
• This can result in significant fluid overload and dilutional hyponatraemia as fluid enters circulation via venous bleeds
• Use of glycine as irrigating agent can lead to more neural issues as it can act as inhibitory neurotransmitter

Question 14

How do patients present with TURP syndrome?

Answer 14

• Confusion
• Nausea
• Agitation
• Visual changes

Question 15

What is HOLEP?

Answer 15

• Holmium laser enucleation of prostate
• Using Holium:YAG laser
• Used to heat and dissect sections of prostate and bladder
• BUT technically challenging

Question 16

If very large prostate what can be an option, or if not suitable for surgery?

Answer 16

• Very large - simple prostatectomy
• Not suitable for surgery but impact on QOL - prostate artery embolisation

Question 17

Complications of BPH

Answer 17

• High pressure retention - chronic or acute on chronic retention causes post renal AKI
• Recurrent UTI
• Significant haematuria episode