BPH/ED
an increase in cell numbers.
Benign prostatic hyperplasia results from what
- Disorders of venous occlusion may be managed with ligation of deep veins - Experience with vascular reconstructive surgery has ben limited and results have been mixed
Explain Penile revascularization for patients with disorders of arterial system for ED
dihydrotestosterone (DHT) and aging
Laboratory and clinical studies have identified two factors necessary for the development of benign prostatic hyperplasia:
Disorders of one system often effects the other system
Male reproductive organs are shared with urinary tract. why could this be an issue?
-Bleeding is common -Foley catheter is left in place -Balloon is overinflated with 30-60mL of sterile water and tightly secured to leg -Creates tamponade to compress the prostate and stop the bleeding -Continuous Bladder Irrigation (CBI) is usually kept running for the first 24 hours
Transurethral resection of prostate (TURP) post-op
-Prostate enlargement may occur with risk of urethral obstruction (increased intraglandular pressure) -Increased smooth muscle tone (pre-prostatic sphincter & anterior fibrous muscular zone) -Interfere with detrusor sphincter -Neuron degeneration
Urinary retention can be due to what changes that occur with aging?
Prostatism: symptoms of obstruction and irritation
What are the clinical features of BPH
-2 testicles -Ductal system: epididymis, ductus deferens, and ejaculatory ducts -Accessory Glands: seminal vesicles, prostate gland, and bulbourethral or cowper's glands -External genitals: urethra and penis
What are the components of the male GU
- Vasectomy-sterilization of the male. - Surgical procedure performed on the vas deferens for the purpose of interrupting the continuity of the duct. - Considered permanent but occasionally a vasectomy with microsurgery.
What are the permanent male contraception
- Involves the use of spermicidal creams, gels, or foams applied before intercourse to kill sperm in the vagina - These are more effective when used with a condom. - Latex condoms provide some protection against sexually transmitted infections (STIs).
What are the reversible male contraception
- decreased libido - decrease in volume of ejaculate - erectile dysfunction
What are the side effects of 5-alpha-reductase inhibitors
-Hyperplasia of stromal and glandular elements of prostate -Gland enlargement creates prostatic urethral narrowing that affects bladder emptying, which can lead to bladder wall hypertrophy distention -In severe hypertrophy, ureters dilate, hydronephrosis and renal impairment ensue
What happens in BPH
-Benign enlargement of prostate gland -AKA Benign Prostatic Hypertrophy, Prostate Enlargement
What is Benign Prostatic Hyperplasia (BPH)
-Rare disorder consisting of prolonged erections without sexual excitation -Penile erection lasting longer than 4 hours resulting in ischemic injury of the corpora cavernosa from venous congestion and cessation of arterial inflow -MEDICAL EMERGENCY
What is priapism
-Mean age of onset is 60-65 years old -Almost 25% of men who live to their eighth decade require treatment for this disorder
What is the age related to BPH
BPH
What is the most common benign tumor in men
-provide secretions for semen -aid in ejaculation -Does NOT secrete hormones
What is the purpose of the prostate
- occult blood from any stool on the finger
What should be evaluated after the DRE
low-flow (venous)
Which type of flow is most common in priapism
-Abrupt onset more likely suggests psychogenic causes, especially if morning erections persist -Gradual worsening of symptoms indicates systemic cause
abrupt onset vs gradual worsening of erectile dysfunction
-Testosterone injections if levels are low (prostate cancer has been excluded) -Vacuum pumps (constriction devices) -Penile revascularization for patients with disorders of arterial system -Penile prosthesis may provide relief: may be implanted directly into corporal bodies (Prostheses may be rigid, malleable, hinged, or inflatable)
additional management options for ED
differences from BPH: UTI = identified by UA with C&S similarities to BPH: UTI = Irritative symptoms similar to BPH
compare & contrast UTI & BPH
differences from BPH: carcinomas = elevated PSA or abnormalities on DRE similarities to BPH: carcinomas = Irritative symptoms (then UA reveals hematuria)
compare & contrast carcinoma of prostate & BPH
-AKA Impotence -Consistent inability to generate or maintain an erection with sufficient rigidity to allow sexual intercourse more than 25% of the time
describe erectile dysfunction (ED)
-Digital Rectal Examination should be performed, gently palpating contour of prostate - smooth, firm, elastic enlargement of the prostate -Enlarged uniform prostate, non-tender, and free of nodules -Size does not always correlate with degree of symptoms -Also assessing for sphincter tone (should have tone - if not it's not BPH) -Conduct a focused physical examination to assess the suprapubic area for signs of bladder distention and a neurological examination for sensory and motor deficits -Decreased anal sphincter tone or the lack of a bulbocavernosus muscle reflex may indicate an underlying neurological disorder
describe the PE necessities for suspected BPH
𝛂1-blockers block the 𝛂1-adrenergic receptors -> relaxes smooth muscles including : -pre-prostatic sphincter -anterior fibrous muscular zone -detrusor muscle -Provides improvement in symptoms; does NOT change size of prostate - just relaxes smooth muscle
describe the action of alpha-1 blockers
-Erection, with glans penis and corpus spongiosum typically not engorged -Low flow: very PAINFUL -High flow: little or no pain usually secondary to trauma -End result: ischemia with necrosis, infarction, infection, urinary retention, impotence
describe the clinical features of priapism
-50% stromal fibrous & smooth muscle -50% glandular
describe the composition of the prostate
- As prostatic enlargement occurs, mechanical obstruction may result from intrusion into the urethral lumen or bladder neck, resulting in a higher bladder outlet resistance. Prostatic size on DRE correlates poorly with symptoms. - The dynamic component of prostatic obstruction explains the variable nature of the symptoms. The prostatic stroma is composed of smooth muscle and collagen and is rich in adrenergic nerve supply. The level of autonomic stimulation thus sets a "tone" to the prostatic urethra. Alpha-blocker therapy decreases this tone, resulting in a decrease in outlet resistance.
describe the difference between mechanical and dynamic obstruction in BPH
Grade 1 = into a non dilated ureter Grade 2 = into the the pelvis and calyces without dilation Grade 3 = mild to moderate dilation of the ureter, renal pelvis, and calyces with minimal blunting of the fornices Grade 4 = moderate ureteral tortuosity and dilation of the pelvis and calyces Grade 5 = Gross dilation of the ureter, pelvis, and calyces; loss of papillary impression; and ureteral tortuosity
describe the grades of vesicoureteral reflux
-Sits at base of bladder (walnut size) -Wraps around upper part of urethra -Seminal vesicles also pass through prostate
describe the location of prostate
-Patient education regarding condition -Avoidance/Discontinuation of drugs that can worsen the condition -Observation vs medical vs surgical treatments should be based on degree of symptoms and whether renal impairment is present -Watchful waiting
describe the management of BPH
-In low-flow cases, injections directly into the corpora with 𝛂-adrenergic agents, phenylephrine unless contraindicated (patients with cardiac or cerebrovascular history) -Needle aspiration of corpora -Recurrent or prolonged episodes require surgical treatment -Attempt to treat underlying disease process; sickle cell patients often benefit from hydration, +/- transfusions -Ice packs, pressure dressings, cold and hot enemas, nitrates, hypotensive agents have been tried
describe the management of priapism
-Transurethral resection of prostate (TURP): most used to relieve obstructions caused by an enlarged prostate -Transurethral incision of prostate (TUIP): incision into the gland -Transurethral ultrasound-guided laser: induced prostatectomy used to relieve obstruction -Radical prostectomy: removal of the entire prostate gland when the gland is very large, is causing obstruction, or is cancerous -Balloon dilation, stents, laser, microwave irradiation, U/S techniques also possible therapies under continuing development
describe the surgical management options for BPH
-Hormonal therapy with, a 5𝛂-reductase inhibitor, REDUCES prostate size and symptoms -Inhibition of 5-alpha-reductase type 2 blocks the conversion of testosterone to DHT, resulting in lower intraprostatic levels of DHT -This leads to inhibition of prostatic growth, apoptosis, and involution -Maximal reduction in prostate volume (~20%) requires 6 months of therapy. -ex. Finasteride (Proscar) and Dutasteride (Avodart)
describe the use of 5-alpha-reductase inhibitors
-FDA approved to treat signs/symptoms of PSA -also for men with both urinary symptoms and erectile dysfunction (ED) -Significant improvements in standardized measurements of urinary function between 2 and 4 weeks after initiating treatment at 5 mg once daily, with minimal adverse effects. -ex. Tadalafil (Cialis)
describe the use of Phosphodiesterase-5 enzyme inhibitors
- Local anesthesia is used - Incision made into the scrotal sac on each side and vas is lifted out. - Instruct patient to use ice applications and acetaminophen or ibuprofen for scrotal pain and swelling for the first 12 to 24 hours post-op. - 2 negative sperm counts are needed for patient to be considered infertile.
describe the vasectomy on an outpatient basis
Depending on the cause: -CBC -UA -Lipid profile -thyroid function tests -glucose -prolactin screening -Serum testosterone level
diagnostic lab studies for erectile dusfunction
-Nocturnal penile tumescence (NPT) -Direct injection of vasoactive substances into the penis induce erections in men with intact vascular systems (after inadequate response to oral meds): Prostaglandin E1, papaverine, phentolamine, or a combination
diagnostic rad studies for ED
differences from BPH: urethral stricture = Hx of prior urethral instrumentation, urethritis, trauma
differences of Urethral stricture/ bladder neck contracture from BPH
differences from BPH: bladder stones = Hematuria/pain
differences of bladder stones from BPH
differences from BPH: Neurogenic bladder = Hx of neuro dz, stroke, DM, back injury, simultaneous alterations in bowel function -diminished/altered LE sensation, rectal sphincter tone
differences of neurogenic bladder from BPH
-Both meds may reduce serum PSA by as much as 50% -Maximally achieved when the maximal decrease in prostatic volume is noted (6 months) -Thus, one must take this into account when using PSA to screen for prostate cancer
explain how Finasteride (Proscar) & Dutasteride (Avodart) reduce serum PSA
-Injection therapy or urethral suppositories provide safe, acceptable, and effective treatment -Intracorporal injection therapy with prostaglandin (PGE1), combination of papaverine and phentolamine, Caverject also used -Priapism and fibrosis are occasional adverse reactions
explain testosterone injections for ED
-mild: less than or equal to 7 -moderate: 8-19 -severe: 20-35
explain the mild, moderate, & severe score ranges of the I-PSS
-Thorough sexual history taking should disclose duration, nature of onset, and impotence. -Also include detailed information on timing and frequency of sexual relations, partners, presence of morning erections, ejaculation, and masturbation -Ability to attain but not maintain may be the first sign of endothelial dysfunction and further CV risk stratification is warranted
explain the pertinent sexual history needed for erectile dysfunction
-Palpation begins at the apex of the prostate and progresses toward the base to determine the size of the gland and assess its consistency -Normal gland resembles that of the thenar eminence when the thumb and little finger are opposed -Prostate cancer typically feels like a harder nodule -Abscess is typically fluctuant -Acute prostatitis, the gland can be quite tender, which can be a diagnostic finding -However, care should be taken NOT to manipulate the prostate vigorously, because of the risk of bloodstream infection -Note is made of the central sulcus of the prostate, and the lateral lobes are evaluated with respect to size and consistency -Seminal vesicles, located proximal to the base of the prostate, should be assessed because these structures may be absent in certain conditions or involved in invasive cancers
explain the technique of conducting the DRE
-Spread buttocks and inspect the anus, posterior perineum, and gluteal folds -Identify pathologic conditions such as condyloma, external hemorrhoids, abrasions, decubitus ulcers, abscesses or cellulitis, and, occasionally, malignancies (eg, melanoma and anal or rectal carcinoma). -Non-dominant hand is then placed on the patient's anterior pelvic bone to provide counter-traction -Dominant hand, with generous lubrication, slowly advances only the index finger through the sphincter and into the rectum -After a few seconds, the sphincter should relax slightly, at which point the digit is advanced further -Note should be made of sphincter tone, which can be lax or absent in neurologic diseases. -Palpation of the internal structures then proceeds in a systematic fashion
explain the technique of inserting finger into rectum for the DRE
-most uroselective -Can relieve bladder outlet obstructive symptoms within 24-48 hours of dosing
explain the use of Tamsulosin
draw the penis into an erect state and block venous outflow to maintain an erection for intercourse
explain the use of vacuum pumps for ED
-Patient is anesthetized and surgery is performed with a scope -Resectoscope inserted into the urethra and prostate gland is "chipped away" a piece at a time -Chips are flushed out using an irrigating solution and are sent to lab for analysis -Gland is not completely removed but peeled back like an orange
explain what is involved with Transurethral resection of prostate (TURP)
arterial, venous, neurogenic, hormonal, or psychogenic causes
loss of erections may result from what?
androgen deficiency
loss of libido may indicate what?
-Hypertension -diabetes -endocrine disease -medications -dyslipidemia -depression -neurologic disease -CKD -CVD -Pelvic surgery, trauma, or irradiation -Prostate cancer -Peyronie disease
pertinent past medical history for erectile dysfunction
-PDE5 inhibitors are the most commonly used treatment & is First Line therapy for ED. Examples: Sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), and avanafil (Stendra) -Contraindicated in patients using other forms of nitrates -Potential hypotensive effects of nitrates with its use -Drugs such as yohimbine and trazodone have been tried
pharmacologic managenement of ED
-Behaviorally oriented sex therapy for psychogenic impotence -Organic impotence patients may also benefit from counseling
psychotherapy use for ED
useful in eliminating symptoms, but carries slight risk of anesthesia postoperative sexual dysfunction
surgery in BPH
-Evaluates sleep erections -Differentiates organic from psychogenic causes -Psychogenic impotence have normal nocturnal erections of adequate frequency and rigidity
use of Nocturnal penile tumescence (NPT) for ED
-Antihypertensive -antidepressant -opioid agents -Alcohol -tobacco -recreational drug use
what are some Drugs associated with ED
Vasovagal syncope: -treated with rest and administration of fluids Disseminated infection resulting from prostatic abscess or acute prostatitis that was massaged too vigorously: -treated with culture-specific antibiotic therapy narrowed from broad-spectrum urinary coverage and supportive care, depending on the nature and severity of the illness
what are some possible complications & treatments resulting from the DRE
-Refractory urinary retention (failing at least one attempt at catheter removal) -Large bladder diverticula Any of the sequelae of BPH: -Recurrent UTI -Recurrent gross hematuria -Bladder stones -Chronic kidney disease
what are the Absolute surgical indications for BPH
-tamsulosin (most uroselective) -silodosin
what are the Partially subtype (alpha-1a)-selective agents for BPH
-Flow rate: Useful in the initial assessment and to help determine the patient's response to treatment -PVR (post void residual) urine volume: Used to gauge the severity of bladder decompensation; it can be obtained invasively with a catheter or noninvasively with a transabdominal ultrasonic scanner -Pressure flow studies: Findings may prove useful for evaluating for BOO (bladder outlet obstruction) -Urodynamic studies: To help distinguish poor bladder contraction ability (detrusor underactivity) from BOO (assess urine flow rate) -Cytologic examination of the urine: May be considered in patients with predominantly irritative voiding symptoms
what are the additional tests that can be used for BPH?
-Duplex U/S scanning used most frequently to determine penile blood flow -Angiography (pelvic arteriography) used for patients who may be surgical candidates -Cavernosonography
what are the additional vascular testing to distinguish arterial from venous ED?
-Alpha-1a-receptors are localized to the prostate and bladder neck -Selective blockade of these receptors results in fewer systemic side effects than alpha-blocker therapy (orthostatic hypotension, dizziness, tiredness, rhinitis, and headache), thus obviating the need for dose titration
what are the benefits of partially subtype alpha-1A selective agents
-Chronic Bladder Outlet Obstruction (BOO) -Recurrent UTI: Urosepsis -Narrowing causes an obstruction and may lead to urinary retention and eventually distention of the kidney with urine hydronephrosis: Urinary retention or Hydronephrosis -Renal insufficiency
what are the complications of BPH
-UA -Urine culture -PSA -Electrolytes, BUN, Creatinine
what are the diagnostic lab studies for BPH
Semen analysis and sperm count is performed
what are the diagnostics of male infertility
-Urethral stricture/ bladder neck contracture -Bladder stones -Carcinoma of prostate -UTI -Neurogenic bladder
what are the differential diagnoses of BPH
-Transrectal ultrasound -Ultrasonography of Abdominal, renal, and/or transrectal
what are the imaging test for BPH
-Nocturia -Frequency -Urgency -Hesitancy
what are the irritative symptoms of BPH
-Weak & intermittent stream -Incomplete voiding -Post-void dribbling -Feeling that the bladder is not empty -Interrupted stream (urine stops mid-stream and then starts again)
what are the obstructive symptoms of BPH?
-terazosin -doxazosin -slow-release (SR) alfuzosin
what are the selective long-acting alpha-1 blockers for BHP
-prazosin -alfuzosin -indoramin
what are the selective short-acting alpha-1 blockers for BHP
-Urinary frequency: The need to urinate frequently during the day or night (nocturia), usually voiding only small amounts of urine with each episode -Urinary urgency: The sudden, urgent need to urinate, owing to the sensation of imminent loss of urine without control -Hesitancy: Difficulty initiating the urinary stream; interrupted, weak stream -Incomplete bladder emptying: The feeling of persistent residual urine, regardless of the frequency of urination -Straining: The need strain or push (Valsalva maneuver) to initiate and maintain urination in order to more fully evacuate the bladder -Decreased force of stream: The subjective loss of force of the urinary stream over time -Dribbling: The loss of small amounts of urine due to a poor urinary stream
what are the symptoms of BPH
-Drugs -infections -systemic disorders
what causes testicular failure?
-intact parasympathetic and somatic nerve supply -unobstructed arterial inflow -adequate venous constriction -hormonal stimulation -psychological desire *Disorders of ANY of these may result in impotence
what do normal erections require?
Intraoperative floppy iris syndrome (IFIS) -characterized by miosis, iris billowing, and prolapse in patients undergoing cataract surgery who have taken or currently take alpha-1-blockers
what is a complication of alpha-1 blockers
The American Urological Association (AUA) symptom index (range from 0-35) -international prostate symptom score (I-PSS) asks identical questions to the AUA
what is perhaps the single most important tool used in the evaluation of patients with BPH and should be calculated for all patients before starting therapy?
high-flow (arterial) or low-flow (venous) status
what is priapism divided into?
-Reflux of urine from bladder retrograde into ureter -Reflux of urine from ureter into renal pelvis -Degree of hydronephrosis
what is the Vesicoureteral Reflux Grade based on?
MRI used to detect thrombosis associated with priapism
what is the diagnostic study for priapism
-Etiology unclear, but androgens (testosterone) are a factor, as demonstrated by lack of this condition in castrated men -No known cause other than normal aging
what is the etiology of BPH
-Neurologic, vascular, endocrine disorders as well as trauma/surgery, drugs, psychogenic causes contribute -Lack of neurologic intervention, blood supply, and circulating hormones are some predisposing factors -Most cases of male erectile disorders have an organic rather than psychogenic cause -Nearly all cases have a psychogenic component -Condition affects millions of American men and its incidence is age related
what is the etiology of erectile dysfunction
-Idiopathic- 40-50% -Sickle cell disease- 11% -Drugs & alcohol- 20% -Injection of erectile-aiding agent- 30% -Trauma- <10%
what is the etiology of priapism
detumescence (deflate) and preserving potency
what is the goal of treatment of priapism
-Alpha1-adrenergic receptor blockers: smooth muscle relaxation -Phosphodiesterase-5 enzyme inhibitors: smooth muscle relaxation (Tadalafil) -5-alpha reductase inhibitors: reduce prostate size (Finasteride) -Anticholinergic agents
what is the medication therapy for BPH
-Testicular disorders -Approximately 25% to 30% of infertility causes may be due to male factors
what is the most common cause of male infertility
-Onset and duration of symptoms -General health issues (including sexual history) -Fitness for any possible surgical interventions -Severity of symptoms and how they are affecting quality of life -Medications -Previously attempted treatments
what is the pertinent history of BPH
anticholinergic agents
what medication should you particularly pay attention to due to its ability to cause difficulty urinating?
-VS (htn), Body habitus, secondary sexual characteristics (endocrine abnormalities) -Thorough cardiovascular exam (vascular abnormalities) -Motor and Sensory exam (peripheral neuropathy/ neurologic abnormalities) -Examination of genitals, auscultation for bruits, perineal pinprick sensation, rectal tone, prostate examination, penis for plaques or deformities, and testes for size, shape, and position: Look for penile deformities (Peyronie's disease), testicular atrophy -Evaluation for impotence not standardized
what should be conducted during the PE for suspected erectile dysfunction?
-Mild symptoms (IPSS/AUA-SI score ≤7) -Moderate-to-severe symptoms (IPSS/AUA-SI score ≥8) who are not bothered by their symptoms and are not experiencing complications of BPH -Medical therapy is not likely to improve their symptoms and/or quality of life (QOL)
when is watchful waiting indicated for BPH?
-Follicular stimulating hormone (FSH) and Luetinizing hormone (LH) may be required in pts with abnormalities of testosterone or prolactin (low levels) -Distinguish hypothalamic-pituitary dysfunction from primary testicular failure
when may additional hormone testing need to be done for ED?
-Management of LUTS in patients who do not have an elevated PVR (postvoid residual) and whose LUTS are primarily irritative -Baseline PVR should be obtained prior to initiation of anticholinergic therapy, to assess for urinary retention
when should anticholinergic agents be used?
-in patients scheduled for invasive treatment or in whom a foreign body or malignancy is suspected -In addition, endoscopy may be indicated in patients with a history of sexually transmitted disease (eg, gonococcal urethritis), prolonged catheterization, or trauma
when would cystoscopy (endoscopy) be indicated?
Nonselective alpha-blockers = phenoxybenzamine
which alpha-1 receptor blockers are NOT recommended?
Combination therapy and finasteride
which medications alone reduced the long-term risk of acute urinary retention and the need for invasive therapy?
-Although BPH does not cause prostate cancer, men at risk for BPH are also at risk for this disease and should be screened accordingly -May be slightly elevated (normal= <4.0)
why is a PSA necessary for BPH?
Assess for the presence of blood, leukocytes, bacteria, protein, or glucose
why is a UA preformed for BPH?
Exclude infectious causes of irritative voiding and is usually performed if the initial urinalysis findings indicate an abnormality
why is a urine culture preformed for BPH?
-to identify any internal hemorrhoids that may be present and thrombosed -to determine whether the consistency is smooth -to detect any stool present and assess its consistency
why is circumferential palpation of the rectal vault also preformed with the DRE?
-Used to help determine bladder and prostate size and the degree of hydronephrosis (if any) in patients with urinary retention or signs of renal insufficiency -Generally, they are not indicated for the initial evaluation of uncomplicated LUTS
why is transrectal ultrasounds used for BPH?
-Screening tools for chronic renal insufficiency in patients who have high post-void residual (PVR) urine volumes -However, a routine serum creatinine measurement is NOT indicated in the initial evaluation of men with lower urinary tract symptoms (LUTS) secondary to BPH
why would you test electrolytes, BUN, & creatinine with BPH? (note: these are not 1st line tests)
