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UKMLA Final Year Series: BPH and LUTS

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Summary

In this on-demand seminar, medical expert Hasan delves into the complex world of Benign Prostatic Hyperplasia (BPH) and lower urinary tract symptoms. Participants will gain a comprehensive understanding of the pathology, epidemiology, and common symptoms associated with BPH. The session also devotes considerable attention to the diagnosis and management of these conditions, giving professionals the knowledge to confidently suggest treatment options to their patients and recognize potential complications before they arise. This class includes a variety of interactive elements, with participants encouraged to provide inputs and engage in brainstorming activities. With this session, medical professionals can refine their problem-solving skills and enhance their proficiency in handling male urinary conditions.

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Description

A session that explores the diagnosis and treatment of Benign Prostatic Hyperplasia and the lower urinary tract symptoms it causes, based off the UKMLA content map.

Learning objectives

  1. Understand the pathology and causes of benign prostatic hyperplasia (BPH) in detail.
  2. Identify and describe the symptoms related to benign prostatic hyperplasia.
  3. Learn about the various methods of diagnosing BPH and identify their potential limitations.
  4. Become familiar with the complications that can arise from BPH and the reasons for their occurrence.
  5. Understand and discuss various management techniques for BPH, including lifestyle changes and medical interventions.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

No, doesn't. Yeah. Ok. Hello everyone. Uh My name is Hasan and welcome to tonight's session on benign prostatic hyperplasia and lower urinary tract symptoms. I'll just give it a couple more seconds for everyone to join and then we'll get started. Ok. Um That should be enough time. Um Let's get started. So, our main learning objectives for today are to learn about the path pathology behind benign prostatic hyperplasia. Some of the symptoms you can get and some of the ways we manage it at the end, we'll touch on the causes of manage management of urinary incontinence and this is mainly in men. Let's get started. I thought um we can get started with a warm up. Um Let's say we're working in Ed and a 67 year old male presents with urinary retention. What do you think could be causing the retention? Would you like to put it in the chat? So I give as broad differential as you can, medication. That's correct. Like um anticholinergics. A thank you. Anything else? Mhm Urethral strictures. That's very true. Um That can cause uh retention, obviously B ph um which is the topic of a thing. Um broadcaster. Yep. Um, stricturing again, infection. Yep. And a uti um you can get retention stones unless they're very, very big. Um But normally they don't cause retention. If they were that big, they probably get stuck up higher in the ureter and don't make it down through the bladder to the urethra. But those are a good differential. So our main one obviously is BPH uti, like you mentioned, hematuria and clot retention and this is where you bleed the blood pools in your bladder. It forms little clots and this just blocks the opening of the urethra. We mentioned stricturing medication like anticholinergics, alcohol. There have been some studies and some people present, you know, after binge drinking alcohol, some men go into attention and also neurological diseases. Um and this is where you have like impaired nerve conduction, you know, you're unable to relax your sphincter. But mainly we're gonna focus on BPH benign prostatic hyperplasia. Um I thought we started off by talking about some anatomy of what essentially is the prostate. Um So this is an organ involved in reproduction and its main function is to keep semen fluid. So it can flow through. Um and you know, in population fertilize the egg and it does this by secreting enzymes into semen to break down clotting factors. And you can see in the diagram there, the location of the prostate um just, you know, in front of the bladder. I've shown another diagram here and this is like a coronal view. So imagine someone's wearing a crown, it's cut right down. And you can see that the urethra sort of passes through the prostate or the prostate sort of hugs it. And this is why if it gets enlarged, it can cause symptoms. So what exactly causes BPH? And this is essentially proliferation of the cells that surround the urethra. So you can see from our diagram in normal prostate, the cells are normal size. There's enough of a lumen for urine to pass through or in, in BPH, the cells around the urethra enlarge and it blocks it up and there's no exact cause, but it's thought to be due to dihydrotestosterone which stimulates the growth of the prostate and what you need to know about it is it's a steroid hormone and it's made from the conversion of testosterone to dihydrotestosterone. And it's something we should park in the back of our mind for now because it comes in later with management. Main risk factors for BPH is old age if you go to a Urology ward, um it's mostly full of old men. Um because those are the people where BPH affects the most, also family history and also metabolic disease. So, um I thought we do some epidemiology. Um Would you like to guess what the incidence is in men aged 60 to 70 years old? Like as a percentage out of 100 you can put it in the chat if you want 30% 40% 20% 6070 50%. Yeah. So we're getting higher. Um, and let's say above 70 what do you think the percentage would be more or less? So? 75? Yup. It's definitely higher. 70%. Yeah. So if I show you the actual statistics in 67 year old, it's about 50 to 60% above 70 it's 80 to 90%. So you can pretty much guarantee that as a man gets older and he's above 70 year olds, you will have some degree of prostatic hyperplasia. Um What do you think some of the common symptoms of BPH are bearing in mind that, you know, the normal way we pass urine is relaxation of the sphincter, compression of the bladder muscles and flow through. So, if we have a prostate, which is narrowing the lumen, what are some of the symptoms, you know, other than retention, you think we'd get instead poor stream. That's very true. One of the main voiding symptoms, we get hesitancy. Absolutely. So the main way if we can break up the symptoms is done in the literature frequency. And I see very true is if we look at storage symptoms and voiding symptoms, so storage symptoms was quite literally is problems in storing the urine. So we have increased frequency, which is the need to go much more often nocturia, which is having to go multiple times at night. Urge incontinence. This is where you suddenly get the urge to go and you can't make it to the toilet in time. And so you wet yourself and also a sense of urgency. And then now if you go into voiding, this is where we get your poor flow, your hesitancy, this is, you know, incomplete, emptying, you go to the toilet and you still feel like there's self enough or terminal dribble, it just seems to keep dribbling out as well as straining. So let's say someone comes to you in Urology clinic and they mention these things that I'm having trouble with my urine flow. You know, it's very poor. I have terminal dribbling. What investigations you like to do. How would you think we could diagnose it? Ok. Mhm. This include bedside tests or imaging or anything like that? Dr Very true. Um, digital rectal examination. Anything else? All right. So, yeah, the main thing. Um, well, the first line thing you do is digital rectal examination. So you gain consent, you wear a glove use or two gloves just to be safe. Um And you use some and basically what you're looking for is a process that's firm, smooth, symmetric and enlarged. If it feels foggy or asymmetric, it's likely to represent a malignancy. But if it's smooth and enlarged, it's most likely BPH, some more things we could do is postvoid bladder scans. And this is essentially you ask the patient to urinate and after urination, you use an ultrasound machine to measure the volume of fluid left in the bladder and you'd expect high residual volume. So even after they've been to the toilet, they've got 102 103 100 mils, you sometimes go up to a liter and again, um urodynamics and these are tests to check the flow. Um and these help you diagnose it. But the thing is they only give you clues. A true diagnosis of BV is based on pathology. Um essentially with your previous tests and imaging, you can only really say that the prostate is enlarged. It's kind of hard to know unless you take samples and biopsies and send it off to the lab to see whether it really is BPH or caused by something else like a malignancy. So these are some images I put of slides to show you what the normal glands look like and what they look like when they've enlarged. Um imaging is quite useful as well. Our first line imaging would be ultrasound and you can see it there in the red circle, enlarged prostate. And one of the main ones that's quite useful is MRI or more specifically multiparametric MRI. And there's something called the PA scale, which is I believe from 1 to 5. And it's used to tell you the likelihood that the prostate is enlarged due to BPH or malignancy. So the higher up the scale, the more likely it's malignancy and the more likely you need to do some biopsies to rule that malignancy. So, these are the main complications. So we've obviously touched on retention if we move to hematuria. Does anyone know why having an enlarged prostate can cause hematuria take? So, it's a bit of a tricky question. But the main thing is typically larger prostates are very vascular. You know, they have a lot of blood supply which has helped them grow. And typically these blood vessels that form can get damaged quite easily. And you can get a lot of bleeding bladder, calculi of stones are due to the fact that you can't empty your bladder, you get stagnant urine for a while and this encourages the development of stones. And the main thing that we worry about is hydronephrosis or hydroureter nephrosis. And this is essentially, if you have difficulty emptying, you raise the pressure of the bladder and if you raise the pressure of the bladder, you can get backflow up the urethra to the kidney. And this causes hydronephrosis or enlargement of the kidney. So if you look at the MRI scan is, if we've cut through someone, you can see that the ureters, which are the renal pelvis, pelvis or pelvi, which should be quite thin, are very enlarged and this can cause AK I CKD. And that's the main thing we're worried about and that's the main thing we want to prevent. So we've talked about, you know what the prostate is, what can cause BPH and some of the complications. So we're looking into management now and this management is to improve the symptoms as well as prevent hydro nephrosis. So, if we're looking mainly at symptoms of hesitancy, nocturia, urgency and frequency, um what we first recommend is reducing excess fluids during the day and especially before sleeping. So this particularly targets nocturia. So if someone complains that um having to wake up three times, four times a night to pee if they reduce the amount of fluids they take beforehand, there's less likelihood of them needing to pee caffeine and alcohol. Um typically act as diuretics, make people pee more. So reduce them, you improve symptoms, double voiding, which is basically spending longer at the toilet and trying to offer the initial forward a bit more. And pelvic floor exercises, these help a lot with incontinence and urge incontinence as it strengthens the muscle and helps reserve the sphincter. So lifestyle also includes catheters. So there's two options. Typically you can offer people, one is intermittent self catheterization. You'll see that in notes written as is and this is where you teach someone to basically self catheterize themselves and they'll do this a couple of times a day. Can you think of anything that can go wrong if you keep catheterizing yourself like multiple times a day for a couple of years, like any complications that can arise from that. Yep. Very true. Stricturing because you're putting in a foreign body can cause inflammation and stricturing and chronic uti or even just any uti the fact that you might not have the best aseptic technique and you're introducing bacteria. An alternative to this is a long term catheter, um which basically you put it on a leg bag. So instead of having it, you know, attached to a etter, you can attach to a small leg bag and then you can just empty the leg bag in the toilet a couple of times a day. One problem you have with long term catheters is some patients can find it very uncomfortable. You know, penis is quite a sensitive region. You can get bladder constrictions and it's quite painful. Um, so what we do for these patients is you can offer them a suprapubic catheter. And this is basically where the catheter goes through the abdomen just above the pubic bone. And to be honest, it's the same design as a regular catheter, but it drains through there and it's typically less symptomatic and more comfortable. And our main aim with catheters is to keep pressure low and protect your kidneys. So the reason some of the lifestyle managements we have, does anyone know any medications we can use to help with BPH and some of its symptoms, you just like to put them in the chat. Yeah. Ok. Tamsulosin. Very correct. An alpha blocker. Um, typically the first line thing you try any other medications. Finasteride. Yep. Absolutely. And that works with the other thing we mentioned about hormones earlier. Great job. So if we start off with tamsulosin or alpha blockers, and these basically antagonize the alpha Adreno receptors and they relax the smooth muscle of the prostate. So the muscle relaxers, you get a slightly wider lumen and you improve flow. Typically, these work in 2 to 3 days. So if you have a patient on the ward, they've come in with retention, you've put in a catheter and you know, you start them on the medication, it won't work instantly. So you need to wait 2 to 3 days and then you can try a trial without catheter. Um It's not without its side effects. The main thing is it can get dizziness due to hypotension because basically it works on receptors in blood vessels and causes phase of dilation which drops your BP and also retrograde ejaculation. And this is essentially where instead of ejaculating out of the penis, you ejaculate into the bladder. Yeah, those are some of the side effects moving on. We have Finasteride or dutasteride. My also seems to like finasteride more and this is a five alpha reductase inhibitor. And you know, we mentioned earlier that one of the potential causes of BPH is testosterone gets converted into dihydrotestosterone which increases proliferation of the cells. This blocks that. And so, you know, you have reduced Dione less growth. This being a hormone takes a lot longer to work typically 6 to 12 months. So you have to explain to patients that it's not going to work as quickly as tamsulosin, you have to persist with it to get some benefits. Some of the side effects, you get reduced libido and weaker erections. One of the things which is actually good is it improves alopecia. So some men take Finasteride if they're losing their hair. One thing to bear in mind is it reduces an old value of PSA which is a blood test we use and we only use it to, you know, kind of screen for cancer or you know, you're suspicious of cancer, you check the PSA. So if a patient is on Finasteride, it normally reduces the value to half. So you have to watch out for that if you think of diagnosing a malignancy. Um Another type of medication is anticholinergics like Solifenacin and these help with symptoms of like urgency um and frequency because they reduce bladder activity, they antagonize muscarinic receptors and you know, it calms down the bladder. So you reduce the urge to go that often as they are Musculin receptor antagonists, they cause dry mouth and constipation. And most importantly, if a patient has glaucoma, you can't give them Solifenacin because it can worsen their glaucoma because it acts on the muscarinic receptors. Another type of medication is Mirabegron. Does anyone know why we would use Mirabegron in a patient who has a catheter? It's a bit of a tricky question. So you give a patient they're on a long term catheter and they're getting some type of symptom and we give them Mirabegron for it. Do you know what symptom they might be having? Good? Ok. A bit of a tricky question. It's bladder spasms. So in some men, you put casts in and they get really painful bladder spasms and contractions and mi big can help with that. Uh Yeah. Um Maria, it also helps with um urgency because it relaxes the intrusive muscle and increases capacity. And the problem is it can also cause constipation and UTI S. Yep. Um One thing to point out when you know you're looking at treating BPH is that once you have a patient who suffers from both urgency and frequency, so they're having to go very often very urgently. It's likely too late for surgery and you know, surgery at this point won't help them. And so if you're ever managing it, you need to, for most people, surgical intervention will be, you know, the ultimate management. So you need to try to operate before it reaches then. So if we move on to surgery, does anyone know any type of operations you can do for B ph? Do you like to list them in the chat? Yeah. Mhm So, yeah. TP. Yep. That's very true. And that's the first one I've got TU RP. And this is a procedure where basically you insert a scope through the urethra of the penis. Um It has a little camera and you can visualize the prostate. And what you do is you slowly shave off the inner layer of the prostate. Um And this increases the lumen because we've removed some of the volume of the prostate and can help improve symptoms. So that's basically what a turp is. It's very, very common in urology. It's quite a good elective procedure and typically a patient can recover quite soon and go home the same day. However, um, a turp isn't useful when you have a very large prostate, like more than 100 CCS. Does anyone know any other procedure you can do for someone with a very large prostate? Mhm. The bit of a tricky question. The main thing is Whole app. So, I don't know if you ever spend any time around urologists or urology, Regs Whole App is the main thing they talk about. They're obsessed with it. Um, mainly because it has quite a big private market and you can charge like seven grand for it. But whole app is quite important because it can let you operate on people with very large volume prostates where at isn't useful. So it's called a Whole Lot because you use a Holmium laser. And the basic idea is if you kind of look at the orange peel is the prostate sort of has a capsule that surrounds it. And so what you do is with your laser, you just cut off pieces inside of, of the actual prostate tissue, but just leaving the capsule behind. And once you cut these small pieces, you sort of push them into the bladder. And then you do a process called morcellation where you pull this tissue through. And a whole lot has many advantages. So typically you can do it on bigger prostates. It can be a very quick operation. Half an hour, you have reduced bleeding, you have improved outcomes, so less likelihood of incontinence. And so it's a really great operation to do. The only problem is it has quite a progressive learning curve. You have to do quite a lot of operations before you get good at it. But hold up is one of the newer treatments and quite useful. One of the older treatments for BPH is a simple prostatectomy which is just removing someone's prostate. Um It's also done in malignancy when you have prostate cancer. And this can be done open like through an incision in the abdomen or more commonly these days, uh robotically. And this is where he'll basically remove the prostate and um plug and you basically make an anastomosis between the bladder and the urethra. And so it has its obvious downsides. It's a longer operation, it's more invasive, there's more chance of infection and more chance of bleeding. It'll also have a longer recovery period and you still risk things um like incontinence. So it's, it's less used these days. And so in the summary of the surgical procedures. The main things you do is Turp and Ho LA Tes are quite common, done pretty much everywhere and they're used for smaller size prostates. Whole lap is newer and used for larger size prostates. And typically you can do the procedure within an hour, half an hour and send the patient home with a catheter and at a later date, you can send them for a talk or a trial without a catheter. So talk is something quite common you see on urology wards and to be honest, in loads of wards for anyone who is catheterized, does anyone know how a talk or a trial without catheter would be successful? They don't know like the procedure behind it or what makes the talk successful. Mhm. And passing urine within 24 hours, that's a part of it. But the main thing we care about with a to is how much urine are they passing and how much is left in the bladder. So a successful talk would be you pass a good amount of urine and there's very little left in your bladder. And this is the way you do this is you measure urine output. So they pee into a bottle and you measure it. And also every time they pee you do a bladder scan with an ultrasound machine to check how much is that. So a successful talk would look like something along the lines of you pull out the catheter in the next few hours, they pass the urine twice, they pass 2 to 300 mils. And in the bladder, there's less than 100 mils left. And that would be a successful talk. An unsuccessful talk would be, they pass very small volumes like 50 MS, 70 MS. And the main thing is the residual volume in the bladder goes up. So after urinating three times, the residual volume in the bladder goes from 100 M to 150 MS to 200 MS. And this shows that they're just retaining and retaining and they'll go back into retention. And in that case, you have to put the catheter back in and try it at a later date or try some medications. That's quite important. You'll see it a lot on the wards, like elderly care wards, any surgical ward. And it's mainly about trends is the residual going down and are they passing good volumes of urine? So that kind of covers BPH, um how we diagnose it, how we manage it. Um And now we move on to incontinence. So, incontinence, a simple definition is just an involuntary loss of urine and you can kind of break it into separate categories. So first you'd have stress. So this is when you have raised abdominal pressure, you lose urine, you know, sneezing, coughing, exercising, and this is mainly due to weakness of the sphincter. So it's too weak at high pressures, it fails. Uh Another type is urge incontinence. And this is you get, you're just chilling, you get a sudden urge to urinate and you can't get to the toilet in time and you know, you make a mess and this is typically due to overactivity of the bladder muscle. And finally, you have overflow incontinence. And this is seen typically in high pressure, chronic retention in BPH. So you're so like you have a man in his eighties, he's had BPH for a couple of months, you know, passing less and less urine and he's got quite high pressure. And so the pressure will eventually lead to some urine passing out. And this will typically happen at night. And that's one of the main tells is if a patient comes in and they say I have incontinence at night, it's normally from chronic urinary retention. So the way we manage incontinence, first of all, with diagnosis, it is very helpful to get bladder diaries. And this is you encourage the patient to talk about. They note down every time they've had incontinence, every time they've passed urine and basically what's happening. And again, urodynamics helps with the diagnosis. So for someone with stress incontinence, which is where. So with stress incontinence, the main things you do are starting with weight loss and physiotherapy. So, physiotherapy would include things like pelvic floor strengthening exercises and this helps you improve the sphincter and tries to reduce the symptoms. You have some surgical procedures. One includes, you know, passing a sling and that kind of acts as your new sphincter or you have an artificial sphincter, which is actually quite cool where it's like an open surgery through the scrotum. And you have a small device which uses like a liquid and pressure and it keeps the sphincter closed. And when you want to pass urine, you can open a valve or play around with a liquid and it relaxes it or opens it and you can pass urine urge incontinence. You typically use medications that we've mentioned. Some call anergic or things like Mirabegron. Again, you can do pelvic floor exercises or sometimes you do Botox injections, which is a surgical procedure under general anesthetic where a surgeon goes in and injects Botox. And this relaxes the muscle of the bladder and prevents it being overactive overflow incontinence. The main way you treat that is you treat the BPH. Um So you can give someone a catheter and this gives them some control, but mainly you want to treat the BPH. So just to summarize what we've covered today, BPH affects the majority of men over 60 above 70. It's approximately 80 to 90% of men. The main treatment you can have lifestyle treatments such as, you know, intimate self catheterization or using drugs. And finally, surgery, which will be a more definitive management and lifestyle measures in patients who are not fit for surgery can improve their quality of life quite a bit. So you should never rule them out and that's the end of our session. Um Thank you for attending. I'd appreciate it if I forget your feedback on how you think the quest uh the session went and if you have any questions, you can put them in the chat. That ok. Yes. Oh, you're welcome. Thanks for coming. Mhm. Ok. That's coming. I've found it useful. I can also put a link in the chat just in case you don't have your phone and I can also link to the next urology session I'm doing if you wanna register and it'll be on stones, which is quite a common topic and quite commonly presented on the wards. And also we have a really good session by one of my colleagues on H PB surgery. Um, tomorrow. So that's the link for that as well. If you like to sign up, I think it would be really good. Quite a high yield topic for exams. Ok. Ok. Well, if there's no more questions, I'll say goodnight to you all. Hope you have a good evening. And good luck with your revision.