Benign Prostatic Hypertrophy

Question 1

Normal Prostate Physiology

Answer 1

• Located under rectum, below the bladder
• Surrounds proximal urethra
• Round, soft, symmetric, and mobile on palpation
• Typically weighs 4-20 g

Question 2

Prostate Gland Tissues

Answer 2

• Epithelial tissue - under androgenic control, produces prostatic secretions
• Stromal tissue: alpha-adrenergic receptors, NE causes contraction which can cause reduced bladder emptying
• Capsule/outer shell: fibrous connective tissue and smooth muscle that can also contract from NE around the urethra

Question 3

BPH Static Factors

Answer 3

• Anatomic enlargement of prostate
• Physical block at bladder neck
• Androgen stimulation of epithelial tissue
• Estrogen stimulation of stromal tissue

Question 4

BPH Dynamic Factors

Answer 4

• Excessive alpha adrenergic tone
• Occurs in prostate gland, bladder neck, posterior urethra
• Contracts prostate gland around urethra

Question 5

Medicated Related Symptoms

Answer 5

• Testosterone replacement: metabolized to DHT
• Alpha agonists: muscle contraction decreased in urethral lumen
• Anticholinergic activity: decreased detrusor muscle contraction causing urinary retention

Question 6

BPH Clinical Presentation

Answer 6

• No acute distress
• Urinary symptoms
• Size of prostate
• Lab tests
• Obstructive symptoms
• Irritative symptoms: occurs later in disease
• Symptoms vary over time

Question 7

BPH Complications

Answer 7

• Chronic renal failure from outlet obstruction
• Gross hematuria when tissue growth exceeds blood supply
• Overflow urinary incontinence
• Recurrent UTI
• Bladder diverticula
• Bladder stones

Question 8

BPH Severity

Answer 8

Mild

• AUASI =< 7
• No symptoms
• Peak urine flow <10 mL/s
• Postvoid residual volume between 25-50 mL

Moderate

• AUASI 8-19
• All of the symptoms above and obstructive/irritative voiding symptoms

Severe

• AUASI >= 20
• All of the above, plus one or more complications of BPH

Question 9

Monitoring/Watchful Waiting

Answer 9

• Reassess every 6-12 month
• Symptoms survery tool
• Digital rectal exam
• Urinary flow rate
• Postvoid residual urine volume
• BUN/SCr
• Behavior modification

Question 10

Alpha Antagonists

Answer 10

• Tamsulosin: more selective in prostate than vasculature
• Silodosin: selective alpha-1 antagonist
• Faster acting and less sexual dysfunction
• SE: syncope, dizzy, hypotension, ejaculatory dysfunction, tiredness

Question 11

5alpha Reductase Inhibitors

Answer 11

• Idea in those with prostate between 40-50 g
• Takes longer to work
• Reduces size by 25%
• SE: ED, nausea, dizziness, gynecomastia
• Dutasteride + Tamsulosin (Jalyn)

Question 12

Alternatives

Answer 12

• No herbals recommended
• Surgery: prostatectomy, laser/ultrasound ablation, microwave thermotherapy (necessary for severe symptoms/complications)