Please enable JavaScript.
Coggle requires JavaScript to display documents.
Benign Prostatic Hyperplasia (BPH) - Coggle Diagram
Benign Prostatic Hyperplasia (BPH)
Epidemiology
Age
50% men >50
Over 70% men age 60-69
Over 80% men >70
90% men age 80+
Prevalence
Risk factors
Unmodifiable
Race: slightly higher prevalence and severity in Black men that White or Asian men
Genetic susceptibility
Fam hx of bladder cancer
Modifiable
Metabolic factors
Obesity
Metabolic syndrome
Excess caffeine
Excess alcohol
Sedentary behavior
Cardiovascular disease
Impact
Most common cause of lower urinary tract symptoms in older men
Leading cause of urinary retention
Leading cause of prostate surgery in aging males
Cost
$1536 associated with BPH diagnosis annually
Avg time lost from work: 7.3hrs annually
Represents 23% of all urology office visits
Health Promotion
Medical Resources
Professional Resources
Urology Care Foundation
American Urological Association
American Academy of Family Physicians
Patient Resources
BPH Advisor App
Assess sx using the International Prostate Symptom Score
Explains treatment options
MyHealth Alberta
provide tips on how to reduce caffeine and alcohol
Penn Medicine
Patient education
Medication adherence and expecting timeline
Warning signs unable to void, sever pain, hematuria
Realistic expectation about symptom improvement
Limit fluids before bedtime and outing
Reduce caffeine intake and alcohol intake
Bladder training exercises
Maintaining healthy weight and physical activity
Information technologies
Telehealth visits for follow up
MyChart for symptom updates
EMR
Disease Management
Follow up
International Prostate Symptom Score (IPSS)
Mild (0-7)
Moderate (8-19)
Severe (20-35)
Referrals
Urology
Nutritionist
Physical therapy
Endocrinology
Treatment
Nonpharmacological Interventions
Pelvic floor exercises
Bladder training
Reduce caffeine intake
Reduce alcohol intake
Reduce fluid intake
Watchful Waiting
Surgical treatment
Transurethral balloon dilation of prostate
Prostatic stents
Transurethral needle ablation of prostate
Laser TURP
Pharmacotherapeutics
5- Alpha Reductase inhibitors
Finasteride (Proscar), Dutasteride (Avodart)
Reduce prostate volume (DHT mechanism)
Arrest disease process
Decrease size of prostate, increase peak flow, Decrease serum PSA
Combination Therapy
Alpha blocker + 5 ARI
For LUST and a large prostate
Addition of an antimuscarinic
Prevent muscle contraction
Ex: Ditropan, VESIcare, Sanctura, Enablex
Alpha Blockers (Address dynamic issue)
Ex: Tamsulosin, Alfuzosin, Doxazosin
Rapid symptom improvement
Relax smooth muscle
Adverse effects: Dizziness, hypotension, ejaculatory problems
Pathophysiology
Hormonal influence
Testosterone
5-alpha reductase type 2 in prostatic stromal cells)
Dihydrotestosterone (DHT)
DHT binds to prostatic epithelial and stromal cells
stimulates tissue growth and cellular proliferation
alters apoptosis mechanisms
Loss of homeostasis
loss of balance b/w prostatic cellular proliferation and apoptosis
Uncontrolled proliferation of prostatic periurethral epithelial and stromal cells
Prostatic enlargement
Bladder outlet obstruction
Diagnosis
HPI
OLDCARTS: onset, duration, severity, exacerbating and relieving factors, degree of bother
Irritative(storage) symptoms: urinary frequency, urgency, nocturia, urge incontinence, dysuria
Obstructive symptoms: decreased stream force, urinary intermittency or hesitancy, post-void dribbling, sensation of incomplete emptying, overflow incontinence, urinary retention
Associated symptoms: hematuria, lower abdominal pain may suggest other causes
Past Medical and Surgical History
previous trauma or instrumentation
Neurologic diseases
Poorly controlled DM, obesity
Medication History
Anticholinergics may impair bladder contractility
Sympathomimetic agents may increase outflow obstruction
Other medications associated with LUTS: antidepressants, diuretics, antihistamines
Family history of BPH or other urinary conditions
Social history
Cigarette smoking
Diet
Foods that may increase risk and symptoms: excessive alcohol use, heavy caffeine intake, high dose Vit C
Physical Exam
Abdomen and pelvis for palpable lumps, masses, hernias
External genitalia: meatal stenosis, testicular abnormalities, phimosis
Motor and sensory evaluation of pelvis and lower limbs
DRE for prostate size, shape, symmetry, nodularity and consistency
Typical findings in BPH: non-tender, smooth enlarged prostate
Diagnostics
Labs
UA to rule out other causes
Urine cytology if hematuria is present
Serum creatinine if evidence of kidney impairment
FBG or HgA1C if not previously completed
PSA if appropriate
Validated screening tool such as IPSS
Post-void residual measurement
If high then renal US
Selected patients: prostate imaging, cystoscopy, urodynamic testing