11- BPH

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Questions and Answers

What does BPH primarily refer to in a clinical context?

Histological diagnosis of prostatic enlargement (correct)

Benign obstruction due to bladder neck problems

Benign Prostatic Hyperplasia as a symptom complex

Benign enlargement of the prostate without histological diagnosis

Which of the following is a characteristic of Lower Urinary Tract Symptoms (LUTS)?

Includes both storage and emptying symptoms (correct)

Is always associated with BPH

Exclusively caused by urinary tract infections

Only presents as irritative symptoms

What conclusion can be drawn about the prevalence of histological BPH?

It decreases after age 60

It remains constant across all age groups

It is only relevant for men over 80

It significantly increases with age, particularly after 50 (correct)

Which risk factor is least likely to be associated with the development of BPH?

History of urinary tract infections Signup and view all the answers

Which of the following statements about surgical management of BPH is correct?

Surgical options include procedures like transurethral resection Signup and view all the answers

Which term refers to the enlargement of the prostate without obstruction?

Benign Prostatic Enlargement (BPE) Signup and view all the answers

In the context of BPH, what does the term 'static/dynamic components' refer to?

The types of bladder outlet obstruction Signup and view all the answers

Which of the following differential diagnoses is specifically related to conditions other than BPH?

Carcinoma of the prostate Signup and view all the answers

What typical symptom may be associated with both BPH and other urinary conditions?

Increased frequency of urination Signup and view all the answers

What is the primary purpose of PSA in the context of prostate evaluation?

To dissolve semen coagulum and assess prostatitis Signup and view all the answers

Which of the following is NOT a component of the initial evaluation for BPH?

Serum creatinine levels Signup and view all the answers

How is treatment success for BPH primarily measured?

Improvement in IPSS and quality of life Signup and view all the answers

The anatomical change associated with benign prostatic hyperplasia (BPH) is best described as:

Benign Prostatic Enlargement (BPE) Signup and view all the answers

Which of the following conditions can lead to an increase in PSA levels?

Hyperplasia Signup and view all the answers

What symptom severity score indicates moderate to severe symptoms in the IPSS assessment?

8 Signup and view all the answers

What is the purpose of performing a cystoscopy during BPH evaluation?

To visualize the bladder and urethra for operative planning Signup and view all the answers

What is characterized by the acronym BOO in relation to BPH?

Bladder Outlet Obstruction Signup and view all the answers

Which choice lists the correct therapeutic options for managing mild to moderate BPH?

Watchful waiting, medical therapy, and minimally invasive therapies Signup and view all the answers

What histological change is associated with BPH?

Stromoglandular hyperplasia Signup and view all the answers

What is the role of alpha-adrenergic blockers in the treatment of LUTS?

To relieve symptoms associated with the dynamic component Signup and view all the answers

Which isoenzyme is responsible for the conversion of testosterone to dihydrotestosterone (DHT)?

Type 1 5-reductase Signup and view all the answers

What effect does DHT have on the androgen receptor compared to testosterone?

Approximately five times greater affinity Signup and view all the answers

What is the primary benefit of combination therapy with Doxazosin and Finasteride?

It effectively reduces the risk of clinical progression and relieves symptoms Signup and view all the answers

What is a key effect of combination treatment with Tamsulosin and Detrol® for men with bladder outlet obstruction (BOO)?

Improvement in bladder capacity without affecting postvoid residual volume Signup and view all the answers

What is the rationale behind using 5-reductase inhibitors in treating BPH?

To arrest disease progression Signup and view all the answers

How do alpha-adrenergic blockers affect the treatment of acute urinary retention (AUR)?

They prolong time to progression of AUR Signup and view all the answers

What physiological effect does the DHT/androgen receptor complex have?

It alters gene expression Signup and view all the answers

Which receptors are primarily involved in mediating irritative symptoms during LUTS?

Alpha-1A and Alpha-1D Signup and view all the answers

Which of the following is NOT an effect of anticholinergic therapy in managing bladder outlet obstruction?

Increased maximum urinary flow Signup and view all the answers

Study Notes

Benign Prostatic Hyperplasia (BPH)

BPH is a histological diagnosis
BPH is enlargement due to benign growth (can include obstruction)
BPH is often associated with "prostatism" and/or lower urinary tract symptoms (LUTS)
Risk factors for BPH increase with age
Symptoms include irritative (storage) and obstructive symptoms common in LUTS, such as nocturia and urgency.

Learning Outcomes

Able to describe BPH
Able to analyze risk factors and developmental period for BPH
Able to describe lower urinary tract symptoms
Able to evaluate a patient with BPH
List medical therapies
List surgical management types

What is BPH?

BPH is a histological diagnosis.
Prostate enlargement can occur without obstruction.
Bladder outlet obstruction (BOO) may be present and can be static or dynamic (components).

LUTS

Lower urinary tract dysfunction symptoms (LUTS) involve both storage and emptying symptoms.
Symptoms may include nocturia, urgency, and difficulty urinating, related to BPH, but not exclusive to it.
LUTS are frequently included in patient evaluations.

Differential Diagnosis

Urethral stricture is a possible differential diagnosis.
Bladder neck contracture is a possible differential diagnosis.
Bladder stones are a possible differential diagnosis.
Urinary tract infection is a possible differential diagnosis.
Interstitial cystitis is a possible differential diagnosis.
Neurogenic bladder is a possible differential diagnosis.
Inflammatory prostatitis is a possible differential diagnosis.
Medications are a possible differential diagnosis.
Carcinoma of the prostate is a possible differential diagnosis.
Carcinoma in situ of the bladder is a possible differential diagnosis.

Prevalence of Histologic BPH

Prevalence of BPH increases with age.
Relevant data points from various studies are presented graphically, showing prevalence rates across different age groups.

Old Paradigm Versus Subsequent Paradigm

Old paradigm viewed BPH as simple enlargement.
Subsequent paradigm recognized that a prostate might be small with receptors.
A subsequent view includes the enlarged prostate with a different set of possible diagnostic markers and clinical considerations.

BPH/LUTS Pathophysiology

Prostate hyperplasia initiates a chain of events.
BOO occurs as a result of obstruction.
Aging effects may affect the detrusor response.
Primary bladder disease may be present.
Polyuria can occur as a result of any of the conditions linked.

Initial Evaluation

Detailed medical history is important.
Physical exam, including DRE and neurologic exam, is needed.
Urinalysis is part of the evaluation.
Serum creatinine is no longer mandatory but may be important in some cases.
PSA is a marker for prostate cancer and is usually evaluated.
Symptom assessment using the AUA-SS score is essential.

PSA

PSA is produced by epithelial cells.
It cleaves semen.
PSA is often bound to other proteins (ACT).
Elevated PSA can be due to malignancy, hyperplasia, or infection/inflammation.

Clinical & Anatomical and Pathophysiologic Changes

Histological changes in the prostate gland, such as stromoglandular hyperplasia, occur.
Clinical symptoms such as bothersome LUTS can be part of the clinical evaluation.
Anatomical enlargement (BPE) may occur as a result of the histological changes.
Pathophysiological compression of the urethra can result in BOO.

Goals of Therapy for BPH

Reduce symptoms (IPSS/AUA scores).
Improve quality of life (QOL).
Prevent further prostate growth.
Increase maximum urinary flow rate and relieve obstruction.
Prevent long-term complications related to BPH.
Acceptable adverse events profile.

Medical Treatments for BPH, LUTS, BOO

Alpha-adrenergic blockers affect the dynamic component, while 5-alpha-reductase inhibitors impact the anatomic component.
Anticholinergic therapy is effective in reducing storage symptoms often associated with BPH.

Role of α-Adrenoreceptors

Alpha-1 (α-1) adrenoreceptors are involved in smooth muscle contraction in the prostate.
Alpha-1 receptors in the spinal cord influence the detrusor response.
Different alpha subtypes in the urinary tract and prostate can have various effects which can be affected by therapies.

Dihydrotestosterone (DHT) Action

Testosterone is converted to DHT by 5-alpha-reductase.
DHT binds to the androgen receptor.
DHT has a higher affinity than testosterone.
DHT modulates gene expression in a significant way.

Rationale for Combination Therapy

5-alpha reductase inhibitors arrest disease progression, while alpha-blockers rapidly relieve symptoms.
Combination therapy is most effective for preventing clinical progression in specific or selected patients.

Doxazosin/Finasteride/Combination

MTOPS (Medical Treatment of Prostatic Symptoms) studied a combination of doxazosin and finasteride.
The method significantly reduces clinical BPH progression.
This approach can reduce the risk of AUR and other invasive therapies.

Combination Treatment with-Blocker Plus Anticholinergic for Bladder Outlet Obstruction

The proposed combination of Detrol® and Tamsulosin for bladder outlet obstruction (BOO) and overactive detrusor (OAB) has a positive impact on quality of life.
Outcomes include increased bladder capacity, no acute urinary retention, no significant impact on urinary flow or post-void residual urine, and a safe treatment option.

Surgical Therapy

Common surgical therapies, such as TURP, TUVP, Gyrus, TUIP surgeries etc.
Laser procedures, open procedures, such as suprapubic, retropubic, perineal and minimally-invasive procedures including TUMT, TUNA, WIT, TEAP, Botox, and ILC are also options.

Transurethral Resection of the Prostate (TURP)

Advantages include availability of long-term outcome data, good clinical results, treating smaller prostates, low retreatment rate, and low mortality.
Disadvantages include retrograde ejaculation and bleeding, including potential TUR Syndrome.

BPH and Erectile Dysfunction

LUTS and erectile dysfunction (ED) are common in older men.
Sexual function declines with age.
ED is often associated with chronic diseases such as diabetes and hypertension.
A possible link exists between LUTS and ED.
Possible underlying mechanisms for co-existence of ED and BPH, such as diminished quality of life, increased sympathetic tone, ischemia/endothelial dysfunction, or alteration of NO pathways.

Take Home Messages

Aging increases the prevalence of BPH.
Not all men with LUTS have BPH.
Not all men with BPH have LUTS.
Consider combination therapy in specific cases.
Quality of life is a significant factor in treatment decisions.

Additional Information

Presented data show the response to various treatments over time.

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