Benign prostate enlargement/benign prostatic hyperplasia

What is the most common disorder of the prostate responsible for LUTS?

BPE/BPH

When does BPE/BPH occur?

Hyperplasia of the epithelial and stromal components of the prostate gland - leads to progressive obstruction of urine flow and increased activity of the detrusor muscle

What is the main stimulator of growth of prostatic glands?

DHT

What are the symptoms of BPE/BPH?

• Frequency of urination

• Difficulty/delay in initiating urination with variability and reduced forcefulness of urinary stream and post-void dribbling often present

• Acute urinary retention or retention with overflow incontinence

• Digital rectal examination showing smooth enlarged prostate

What are some differential diagnoses of BPE/BPH?

• poorly controlled diabetes

• Neurological disorders

• UTIs

• Chronic bacterial prostatitis

• Overactive bladder

• Medication - diuretics, anticholinergics, antidepressants

• Lifestyle factors e.g., caffeine, alcohol, excess intake of liquids

Why are prostate specific antigen/DRE not routinely required for diagnosis?

BPE/BPH not risk factor for prostate cancer

What are some management options for BPE/BPH?

Observation, lifestyle management, modification of existing medication/managing co-existing medical conditions, prostate and bladder specific drug treatment, surgical treatments

What is management aimed at for BPE/BPH?

Symptom relief, preventing symptom progression and reducing long term complications

What are some lifestyle management advice for BPE/BPH?

Reassurance, reduce fluid or diuretic intake, avoid excess or night-time fluid intake, avoid caffeine, alcohol, void bladder before long trips, meetings or bed time

What comorbidities should be reviewed for BPE?

Diabetes control, diuretic therapies

What are examples of alpha blockers?

Doxazosin, tamsulosin, alfuzosin

What are some examples of non-selective alpha blockers?

Doxazosin

What are some examples of selective alpha blockers?

Tamsulosin, alfuzosin

How do alpha blockers work?

Improve bladder and prostate smooth muscle tone, reviewed patient 4-6 weeks after starting therapy - dilates vessels and works quickly

What other medical condition can alpha blockers also be used for?

Hypertension

What can be a side effect of alpha blockers?

Can decrease hypotension so for 1st dose take in evening due to dizziness/drowsiness, fall risk

How do 5a-reductase inhibitors work?

Reduce prostate size, can be used alone or in combination with alpha blockers

How long do 5a-reductase inhibitors take to work?

Slower onset, 3-6 months on the prostate size

What is an example of 5a-reductase inhibitors?

Finasteride, dutasteride

What else can finasteride be used for?

Male pattern baldness

Who should avoid handling 5a-reductase inhibitors?

Risk of fetal harm so pregnant women

What can be some sexual function side effects of 5a-reductase inhibitors?

Sexual dysfunction, decreases libido, sex drive, ejaculation issues, gynaecomastea, enlargement of breast tissue

What is an example of an antimuscarinic?

Tolterodine - selective M3

How do antimuscarinics work?

Binds to M3 receptors in the bladder and help with incontinence

What criteria is used for antimuscarinics in elderly?

STOP/START

What are some key anti-cholinergic side effects?

Dry mouth, paralytic ileus, tachycardia, urinary retention, constipation, blurred vision/glaucoma, drowsiness, cognitive impairment, sweating, heat intolerance

How do antimuscarinics work?

Hypercontractility of detrusor muscle

What are antimuscarinics useful for?

Symptoms of overactive bladder

What are some other drug treatments for BPE?

Diuretics, desmopressin, phosphodiesterase-5-inhibitors

What are some surgical options for BPE?

Transurethral resection of prostate involving endoscopic removal of inner zones of the enlarged prostate using a diathermy loop

What are the risks of TURP of BPE?

Impotence, incontinence, need for further treatment due to stricture formation, general anaesthetic risk and severe haemorrhage

What are some other surgical options for BPE?

Transurethral incision of the prostate, laser prostatectomy