​Kembara Xtra - Medicine - Benign Prostatic Hyperplasia

​Kembara Xtra - Medicine - Benign Prostatic Hyperplasia 
Benign prostatic hyperplasia (BPH), which can result in urethral compression and obstructive symptoms, is caused by the proliferation of the prostate's smooth muscle and epithelial cell lines.
Lower urinary tract symptoms (LUTS), also referred to as storage and/or voiding symptoms, are a clinical manifestation of BPH. These include nocturia, dysuria, urgency, and/or difficulties starting a urine stream.
There is no direct relationship between symptoms and prostate volume. Only around half of men with histological evidence of BPH are thought to have moderate to severe LUTS; progression can lead to upper and lower urinary tract infections, direct obstruction of the bladder outlet, and acute renal failure (ARF).


Epidemiology 

In men, development is almost universally correlated with age.
Incidence
By the age of 80, the prevalence is thought to range from 70% to 90% (by age 40, it is thought to be between 8% and 20%).

Pathophysiology and Etiology 

Unknown cause; occurs in the transition zone or periurethral region of the prostate gland; hyperplastic nodules of stromal and epithelial components that enhance glandular components.

Ageing is a risk factor, as is having heart disease and using beta-blockers. Low androgen levels from cirrhosis/chronic alcoholism reduce the risk of BPH. Obesity and sedentary lifestyles can worsen LUTS. There is no evidence that smoking, alcohol, or any dietary factors increase or decrease risk.

General Prevention Weight loss, fluid intake control (particularly at night), a reduction in caffeine use, and an increase in physical activity can all help manage symptoms.

Accompanying Conditions 
LUTS can be separated into two categories:
Frequency, nocturia, urgency, and urge incontinence are filling/storage signs.
- Sexual dysfunction, including erectile dysfunction and ejaculatory problems - Voiding symptoms, such as difficulties commencing a urine stream, incomplete voiding, or a weak stream - LUTS may also be a complication of cardiovascular, pulmonary, or renal disease.


Diagnosis 
Determine the severity of symptoms using the International Prostate Symptom Score (IPSS) or the American Urological Society Symptom Index (AUA-SI).
Check for additional factors including infection, past medical procedures, or neurogenic causes.
 Check for co-occurring diseases including Parkinson's disease, diabetes, or congestive heart failure (CHF).
Review your prescription list and any BPH or prostate cancer in your family history.
Check for unpleasant hematuria.
 To identify urine patterns in nocturia (more than twice per night), a frequency/volume chart should be kept for two to three days.


clinical assessment 
Digital rectal examination (DRE): symmetrically enlarged prostate (symptoms and size are not necessarily correlated).
 Obstructive uropathy-related symptoms of renal failure, such as edema, pallor, pruritus, ecchymosis, and nutritional inadequacies
The patient should be sent to urology if the DRE is suggestive of prostate cancer, or if there is hematuria, recurrent infections, concern for stricture, or indications of neurologic disease.

Multiple Diagnoses 

 Neurogenic - Spinal cord injury or stroke Obstructive - Prostate cancer Urethral stricture or valves Bladder neck contracture (often following prostate surgery) Inability of bladder neck or external sphincter to release correctly during voiding 
Parkinsonism and MS are two conditions.
Medical - poorly managed type 2 diabetes - CHF
Pharmacological: Decongestants (increased sphincter tone), Opioids (reduced autonomic function), Tricyclic Antidepressants (anticholinergic), Diuretics (increased urine production),
Other - Prostatitis and prostatitis - Bladder calculi - Bladder cancer - Overactive bladder - Nocturnal polyuria - Urethritis/sexually transmitted illnesses
- Caffeine - Obstructive sleep apnea (OSA) (nocturia)

Initial test results from the laboratory and imaging
Urinalysis (UA) can help rule out additional etiologies such as bladder/kidney stones, malignancy, UTI, or urethral strictures in all individuals presenting with LUTS.
 PSA (particularly in males with a life expectancy of at least ten years who would be candidates for surgery if prostate cancer were found)
PSA levels and prostate volume are correlated, which may help patients choose their treatment.
 If you smoke or have hematuria, which are risk factors for bladder cancer, get a urine cytology and/or cystoscopy.
Consider using a frequency volume chart for urine production if nocturia is your major worry.
Uroflow: the amount of urine passed in a certain amount of time (peak flow of 10 mL/sec is abnormal).
Postvoid residual (PVR): measured by bladder ultrasonography or catheterization (>100 mL = insufficient emptying).
 If OSA or primary nocturnal polyuria is suspected, sleep study

Tests in the Future & Special Considerations
In simple LUTS, no extra testing is advised.
If symptoms are not relieved by medical treatment or if an initial evaluation indicates an underlying condition, more testing may be necessary.
 Prostate gland size assessment using transrectal ultrasonography or cross-sectional imaging (MRI/CT); not required for regular evaluation
 Abdominal ultrasound: not required for regular evaluation but can show elevated PVR or hydronephrosis.
Other/Diagnostic Procedures
 Pressure-flow tests to identify the cause of symptoms (urine flow vs. voiding pressures)
High voiding pressures and poor flow rate are represented by the obstruction pattern.
Cystoscopy can show the existence, configuration, cause (stricture, stone), and location of obstructive tissue. However, it is not advised during routine examination unless additional conditions, such as hematuria, are present.

Management Treatment options include everything from waiting it out to making lifestyle changes, taking medication, or having surgery.
In addition to a yearly repeat evaluation, mild or moderate symptoms (score of 7 or 8 on the IPSS) that are not bothersome don't need to be treated.
 For moderate-to-severe symptoms, try lifestyle measures, such as controlling fluid consumption, abstaining from alcohol and caffeine, exercising, eating a healthy diet, and lowering or stopping contributing drugs.

Adrenergic antagonists are the first line of treatment for moderate to severe annoying conditions.
AUA recommends alfuzosin (Uroxatral), doxazosin (Cardura), and tamsulosin (Flomax) because they are thought to be more selective and have less of an impact on blood pressure. LUTS (2) - Affects smooth muscle contraction in the prostatic urethra and bladder neck - Clinical improvement typically takes 2 to 4 weeks. There is insufficient support for the use of prazosin (Minipress) and phenoxybenzamine (Dibenzyline), hence they are not advised.
Doxazosin (Cardura): 1–8 mg PO daily
0.4 to 0.8 mg of tamsulosin (Flomax) orally each day
 10 mg of alfuzosin (Uroxatral) orally daily
Start with 1 mg PO daily at bedtime, up to 20 mg daily, for terazosin (Hytrin).
- Inhibitory conditions
Patients who are concurrently taking phosphodiesterase type 5 inhibitors for erectile dysfunction should be treated with caution.
Due to the danger of perioperative floppy iris syndrome, men who are having cataract surgery shouldn't use this medication until after the procedure.
5-reductase inhibitors - Block the conversion of testosterone to dihydrotestosterone to gradually reduce prostatic volume - Greatest clinical benefit when prostate volume exceeds 40 mL; therefore, use is discouraged in the absence of prostate enlargement - Typically takes 6 months to show clinical benefits
Finasteride (Proscar): 5 mg PO once daily
Dutasteride (Avodart): 0.5 mg/day PO - Reduces the risk of acute urinary retention and reduces the need for surgical intervention - Used in patients with refractory hematuria after other causes have been ruled out - Side effects include decreased libido and erectile dysfunction; low risk of prostate cancer (3)[C].
ALERT
A patient taking a 5-reductase inhibitor will have an artificially low PSA value of up to 50%. Before and after the start of the treatment, test.
Anticholinergic drugs are appropriate for moderate to severe predominant storage LUTS without an elevated PVR. Combination therapy of a -blocker and a 5-reductase inhibitor is preferable to monotherapy with a -blocker only in men with evidence of enlarged prostates. Options include solifenacin (VESIcare), tolterodine (Detrol LA), or oxybutynin (Ditropan XL); avoid in individuals whose PVR is greater than 250 mL.
Patients with moderate to severe storage LUTS may be prescribed 3 adrenergic agonists in conjunction with a -blocker.
 Tadalafil (Cialis), 5 mg/day PO, can be used to treat LUTS, but should not be used in conjunction with beta-blockers or in people with CrCl less than 30 mL/min, regardless of coexisting erectile dysfunction (3).[B].
Aspects of Geriatrics
Anticholinergics, antihistamines, sympathomimetics, tricyclic antidepressants, and opioids should all be used with caution.

Referral criteria include the following: Moderate or severe LUTS that do not respond to medical treatment BPH-related complications like recurrent UTIs or hematuria, renal insufficiency, and urinary retention Abnormal PSA or prostate exam Any history of urethral trauma or stricture, or neurologic disease of the bladder/urinary system

Surgical Techniques Reasons for Surgery
- Prostatic blockage causing recurrent urinary retention; medicine has no effect.
- Prostatic obstruction symptoms and intractable symptoms (AUA score >8)
- Obstructive uropathy (insufficiency of the kidneys)
Recurrent gross hematuria brought on by an enlarged prostate; recurrent or persistent UTIs brought on by prostatic blockage
Urinary calculi
 Surgical procedures: While TURP continues to be the industry standard, there are various treatments available for certain patient populations.
Common TURP problems include:
bleeding, retrograde ejaculation, urinary incontinence, and TURP syndrome, which is hyponatremia brought on by the ingestion of hypotonic irrigation fluid
Other options include laser enucleation, robotic waterjet treatment (RWT), transurethral vaporization of the prostate (TUVP), transurethral microwave, thermotherapy (TUMT), transurethral incision of the prostate (TUIP), photoselective vaporization of the prostate (PVP), prostatic urethral lift (PUL), and water vapor thermal therapy (WVTT).
Patients using anticoagulants have a choice between PVP, thulium laser enucleation of the prostate, and holmium laser enucleation (HoLEP).
Transurethral needle ablation and prostate artery embolization are not supported by existing data, although PUL and WVTT can be offered as therapeutic options for patients who choose preservation of erectile and ejaculatory function.

Healthcare Alternatives 

No complementary or alternative therapies are advised for the treatment of BPH, and a Cochrane review of extensive studies on saw palmetto (Serenoa repens) found no improvement in LUTS.


Follow-up patient monitoring includes: DRE once a year in patients who choose watchful waiting; PSA once a year in patients who choose watchful waiting; and consideration of PVR monitoring if PVR is elevated. PSA should not be checked while the patient is in retention, has recently undergone catheterization, or within a week of any prostate surgical procedure.

Diet 
Alcohol, caffeine, or large boluses of oral or intravenous fluids may make LUTS worse.

Prognosis: In 70–80% of patients, symptoms get better or stay the same.
After a prostatectomy, 25% of men with LUTS will continue to experience storage symptoms.
11-33% of men with BPH have prostate cancer that is undetected.

Complications include bladder stones, prostatitis, hematuria, and urinary retention (acute or chronic).

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