PANCE Blueprint Genitourinary (5%)

Benign prostatic hyperplasia (Lecture)

Patient will present as → a 70-year-old man with difficulty initiating a stream and post-void dribbling. He also reports having increased urinary urgency, nocturia, and a weak urinary stream. Medical history is significant for hypertension. The patient is not on medication. On digital rectal exam, his prostate is enlarged, non-tender, firm, and smooth. Urinalysis is unremarkable and prostate-specific antigen is elevated.

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BPH is part of the normal aging process but only sometimes causes symptoms (50% of men develop BPH by 60 and > 90% by age 85)

  • Features: Decreased force of urinary stream, hesitancy (stop and start) and straining, postvoid dribbling, incomplete emptying, frequency, nocturia, urgency, recurrent UTIs
  • Acute urinary retention can develop with exposure to cold, prolonged attempts to postpone voiding, immobilization, or use of anesthetics, anticholinergics, sympathomimetics, opioids, or alcohol
  • In men with BPH, avoid use of anticholinergics, sympathomimetics, and opioids

Digital rectal exam - will demonstrate a uniformly enlarged, firm, and rubbery prostate

  • Although cancer may cause a stony, hard, nodular, irregularly enlarged prostate, most patients with cancer, BPH, or both have a benign feeling, enlarged prostate. Thus, testing should be considered for patients with symptoms or palpable prostate abnormalities

PSA is often ↑ in BPH - correlate with risk of symptom progression

  • PSA is considered normal < 4
  • PSA > 4 think BPH, prostate CA and prostatitis

Urinalysis is used to rule out other conditions

Observation is reasonable if mild symptoms - patients should be monitored annually

Alpha-blockers cause urethral relaxation and rapid symptom relief

  • α-1 blockers - tamsulosin (Flomax) most uroselective provides rapid symptom relief - smooth muscle relaxation of prostate and bladder neck decreases urethral resistance and obstruction which increases urinary flow can cause dizziness and orthostatic hypotension as well as retrograde ejaculation

5 ∝ reductase inhibitors (REDUCE THE SIZE) shrink an enlarged prostate

  • 5-α reductase inhibitors - finasteride and dutasteride (androgen inhibitor - inhibits the conversion of testosterone to dihydrotestosterone suppressing prostate growth, and reducing bladder outlet obstruction) has a positive effect on the clinical course of BPH

Phosphodiesterase type 5 inhibitor (PDE5 inhibitor) - tadalafil, in men with BPH-related symptoms and erectile dysfunction

  • PDE5 inhibitors block the PDE5 enzyme to prevent it from working. This inhibition relaxes the blood vessels and increases blood flow
  • Combination therapy with PDE5 inhibitors and alpha 1-adrenergic blockers seemed to have an additive beneficial effect on BPH/lower urinary tract symptoms compared with monotherapy

Surgery is done when patients do not respond to drug therapy or develop complications such as recurrent urinary tract infection, urinary calculi, severe bladder dysfunction, or upper tract dilation.

  • TURP (transurethral resection of the prostate) - removes excess prostate tissue to relieve obstruction - sexual dysfunction and urinary incontinence
  • Transurethral incision of the prostate (TUIP) - electric current to make incisions in prostate - no tissue is removed

osmosis Osmosis
Benign prostatic hyperplasia

IM_MED_BenignProstaticHyperDIagnosis_v1.4_BPH is characterized by increased epithelial cells and stromal components of the lateral and middle glands of the prostate. It can lead to compression of the urethra and various urinary manifestations. Accurately diagnosing BPH is extremely important as more serious conditions, such as prostate cancer must be ruled out. Therapy is typically medical; however, in certain instances, more invasive therapy (i.e. TURP) may be needed.

Benign Prostatic Hyperplasia (BPH) Disease
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Benign Prostatic Hyperplasia (BPH) Diagnosis and Treatment
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Selective Alpha 1 Blockers
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Question 1
A 75-year-old man comes to your office with a 6-month history of nocturia, hesitancy, a slow flow of urine, and terminal dribbling. The symptoms have been progressing. Otherwise, he is well and has had no significant medical illnesses. On examination, his abdomen is normal. He has an enlarged prostate gland, which is smooth in contour and firm and has no nodules or irregularities. What is the most likely diagnosis in this patient?
benign prostatic hypertrophy (BPH)
carcinoma of the bladder
prostatic carcinoma
urethral stricture
chronic prostatitis
Question 1 Explanation: 
The most likely diagnosis in this patient is BPH. Hyperplasia of the prostate causes increased outflow resistance.
Question 2
Which of the following symptoms is (are) associated with the condition described in this case?
daytime frequency
incomplete voiding
all of the above
Question 2 Explanation: 
The symptoms of BPH are described as either obstructive or irritative. Obstructive symptoms are attributed to the mechanical obstruction of the prostatic urethra by the hyperplastic tissue and include the following: (1) hesitancy, (2) weakening of the urinary stream, (3) intermittent urinary stream, (4) feeling of residual urine (incomplete bladder emptying), (5) urinary retention, and (6) postmicturition urinary dribbling. Irritative symptoms are attributed to involuntary contractions of the vesical detrusor muscle (detrusor instability) and are associated with obstruction in approximately 50% of patients with prostatism. These symptoms include (1) nocturia, (2) daytime frequency, (3) urgency, (4) urge incontinence, and (5) dysuria. Differential diagnosis includes carcinoma of the prostate, neuropathic bladder, chronic prostatitis, and urethral stricture.
Question 3
Which of the following pharmacologic treatments may be indicated in the treatment of the condition described in this case?
a, b, and c
Question 3 Explanation: 
The pharmacologic treatment of BPH is directed toward relaxation of the prostatic smooth muscle fibers through inhibition of alpha-adrenergic receptors and toward regression of the hyperplastic tissue by hormonal suppression. The growth of BPH depends on the presence of the androgenic hormone testosterone and its derivative dihydrotestosterone (through conversion by the enzyme 5α-reductase). The strategy of antiandrogenic therapy in BPH is to interfere with dihydrotestosterone production. Many antiandrogenic drugs have been tried, but the most promising are the 5α-reductase inhibitors finasteride (Proscar) and dutasteride (Avodart). They may result in a 20% reduction in prostatic size and a modest improvement of the urine and symptom score; treatment may take up to 6 months to achieve this, and patients need to be aware of the delay. They may be most effective in men with larger prostates (>40 g) and may reduce serum PSA levels by an average of 50%. If the patient improves and side effects are minimal, continuation of therapy is appropriate. The tone of prostatic smooth muscle is mediated by alpha1 adrenoceptor stimulation. Selective or nonselective antagonists relax the smooth muscle, resulting in a diminution of urethral resistance, improvement of urine flow, and significant improvement in symptoms. The results of double-blind, randomized controlled trials have demonstrated the short-term efficacy of selective alpha1 blockade. Selective alpha1 blocking drugs, such as terazosin (Hytrin) and doxazosin (Cardura), represent an option for patients with moderate symptoms, and second-generation medications including tamsulosin (Flomax), silodosin (Rapaflo), and alfuzosin (Uroxatral) may be less likely to cause hypotension and syncope. There are also combination medications on the market, and they should be used cautiously.
Question 4
Before medical treatment of the condition described here, which of the following should be performed?
symptom assessment with a validated screening tool
transrectal ultrasound examination
computed tomography (CT) scan of the pelvis
a and b
Question 4 Explanation: 
The following should be performed before any medical intervention for BPH: (1) a history with use of a validated screening tool, such as the American Urological Association Symptom Index; (2) a focused physical examination; and (3) a DRE. Other studies in evidence-based reviews have been deemed unnecessary. Ultrasound examination (transrectal or abdominal), determination of postvoiding residual urine, routine urinalysis and culture, electrolyte values (especially urea and creatinine), PSA levels, and cystoscopy are sometimes performed when surgical intervention is contemplated or complications are present.
Question 5
Which of the following surgical procedures is the treatment of choice for severe cases of the condition described here?
transurethral resection of the prostate (TURP)
open prostatectomy
transurethral incision of the prostate
hyperthermia of the prostate
balloon dilation of the prostate
Question 5 Explanation: 
In general, TURP remains both safe and efficacious and is the “gold standard” against which all other treatments, both medical and surgical, must be measured. More than 80% of patients experience subjective improvement, including a significant improvement in urine flow rate. Approximately 15%, however, report no benefit 1 year after surgery. Complications of surgery can be significant; some patients are left with chronic incontinence or impotence. The procedure can often be performed under spinal anesthesia, which is preferred in patients with complex medical problems. Other surgical treatment options include some minimally invasive procedures. These include transurethral laser-induced prostatectomy (TULIP procedure), transurethral balloon dilation of the prostate, laser ablation, high-intensity ultrasound thermotherapy, microwave thermotherapy, electrovaporization, and radiofrequency vaporization. An open prostatectomy is indicated for glands larger than 50 g.
There are 5 questions to complete.
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References: Merck Manual · UpToDate

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