MSN 621 - GU Disorders Exam Questions
With Accurate Answers
Define benign prostatic hyperplasia. - ANSWER the nonmalignant growth or
hyperplasia of prostate tissue and is a common cause of lower urinary tract
symptoms in men
What are the different ways to describe BPH? - ANSWER Several definitions
exist in the literature when describing BPH. These include bladder outlet
obstruction (BOO), lower urinary tract symptoms (LUTS), and benign prostatic
enlargement (BPE). BPH describes the histological changes, benign prostatic
enlargement (BPE) describes the increased size of the gland (usually secondary
to BPH) and bladder outlet obstruction (BOO) describes the obstruction to flow.
Those with BPE who present with BOO are termed benign prostatic obstruction.
Lower urinary tract symptoms (LUTS) simply describe urinary symptoms shared
by disorders affecting the bladder and prostate (when in reference to men).
LUTS can be subdivided into storage and voiding symptoms. These terms have
largely replaced those historically termed "prostatism."
What causes the development of BPH? - ANSWER The development of benign
prostatic hyperplasia is characterized by stromal and epithelial cell proliferation
in the prostate transition zone (surrounding the urethra), this leads to
compression of the urethra and development of bladder outflow obstruction
(BOO) which can result in clinical manifestations of lower urinary tract
symptoms (LUTS), urinary retention or infections due to incomplete bladder
emptying.
What can happen when BPH is left untreated for long-term? - ANSWER Long-
term, untreated disease can lead to the development of chronic high-pressure
retention (a potentially life-threatening emergency) and long-term changes to
the bladder detrusor (both overactivity and reduced contractility).
How do hormonal effects of testosterone on the prostate tissue cause BPH? -
ANSWER Although they do not cause BPH directly, testicular androgens are
required in the development of BPH with dihydrotestosterone (DHT) interacting
directly with prostatic epithelium and stroma. Testosterone produced in the
testes is converted to dihydrotestosterone (DHT) by 5-alpha-reductase 2 in
prostate stromal cells and accounts for 90% of total prostatic androgens. DHT
has direct effects on stromal cells in the prostate, paracrine effects in adjacent
prostatic cells, and endocrine effects in the bloodstream, which influences both
cellular proliferation and apoptosis (cell death).
,BPH arises as a result of the loss of homeostasis between cellular proliferation
and cell death, resulting in an imbalance favoring cellular proliferation. This
results in increased numbers of epithelial and stromal cells in the periurethral
area of the prostate and can be seen histopathologically
What are some risk factors for BPH? - ANSWER metabolic syndrome, obesity,
hypertension, and genetic factors. Increasing in age drastically increases the
occurrence of BPH.
Describe metabolic syndrome and BPH - ANSWER Metabolic syndrome refers to
conditions that include hypertension, glucose intolerance/insulin resistance,
and dyslipidemia. Meta-analysis has demonstrated those with metabolic
syndrome and obesity have significantly higher prostate volumes. Further
studies looking at men with elevated levels of glycosylated hemoglobin (Hba1c)
have demonstrated an increased risk of LUTS.
Describe the relationship of obesity to BPH. - ANSWER Obesity has been shown
to be associated with increased risk of BPH in observational studies. The exact
cause is unclear but is likely multifactorial in nature as obesity makes up one
aspect of the metabolic syndrome. Proposed mechanisms include increased
levels of systemic inflammation and increased levels of estrogens.
Describe the relationship of genetics to BPH. - ANSWER Genetic predisposition
to BPH has been demonstrated in cohort studies, first-degree relatives in one
study demonstrated a four-fold increase in the risk of BPH compared to control.
These findings have demonstrated consistency in twin studies looking at the
disease severity of BPH, with higher rates of LUTS seen in monozygotic twins.
Describe the patho of BPH. - ANSWER Both the development of lower urinary
tract symptoms and bladder outlet obstruction in men with BPH can be
attributable to static and dynamic components. Static obstruction is a direct
consequence of prostate enlargement resulting in periurethral compression and
bladder outlet obstruction. Here, periurethral compression requires increasing
voiding pressures to overcome resistance to flow; in addition, prostate
enlargement distorts the bladder outlet causing obstruction to flow.
Dynamic components include the tension of prostate smooth muscle (hence the
use of 5-alpha reductase inhibitors to reduce prostate volume and alpha-
blockers to relax smooth muscle). This is explained by decreases in elasticity
and collagen in the prostatic urethra in men with BPH, which may further
exacerbate bladder outlet obstruction due to loss of compliance and increased
resistance to flow and may explain why prostate size alone is not always a
predictor of disease.
Describe the histopathology of BPH. - ANSWER Histological examination
demonstrates that BPH is a hyperplastic process with an increase in cell
number on histology (hyperplasia); these occur both in the periurethral and
,transition zones. Histological studies have demonstrated both glandular and
stromal proliferation. Specifically, periurethral zones demonstrate stromal
nodules, whereas glandular nodular proliferation is seen within the transition
zone.
Describe the lower urinary tract symptoms of a patient with BPH. - ANSWER
Lower urinary tract symptoms can be divided into storage (frequency, nocturia,
urgency) and voiding symptoms (stream, straining, hesitancy, prolonged
micturition) and can help establish other causes of urinary symptoms such as
urinary tract infections/overactive bladder, in addition to determining the site
affected (bladder vs. prostate). Men with BPH are likely to report predominant
symptoms of nocturia, poor stream, hesitancy, or prolonged micturition.
Describe red flags for BPH. - ANSWER Red flags help point to more sinister
causes of urinary symptoms such as bladder/prostate cancer, neurology such
as cauda equina, or chronic high-pressure retention (which can lead to silent
renal failure). The presence of these can be established by asking about visible
haematuria/bone pain/weight loss, neurology, and nocturnal
enuresis/incontinence, respectively.
Describe the physical exam for a patient with BPH. - ANSWER In the elective
setting, the examination should include abdominal examination (looking for a
palpable bladder/loin pain) and examination of external genitalia (meatal
stenosis or phimosis). The examination should then conclude with a digital rectal
examination making a note in particular of the size, shape (how many lobes), and
consistency (smooth/hard/nodular) of the prostate (BPH is characterized by a
smooth enlarged prostate).
Further bedside evaluation includes
-Urine dipstick (rule out other causes such as infection)
-Post-void residual volume (whether the bladder is emptied properly)
-IPSS (international prostate symptom score)
-Frequency-volume chart
The IPSS stratifies patients into three groups on the basis of symptoms. They
are: - ANSWER mild (0-7), moderate (8-19), and severe (20-35). Those with more
severe symptoms are less likely to benefit from conservative or medical
measures.
How is BPH diagnosed? - ANSWER Standard investigation of BPH may include
bedside urine dipstick, post-void residual, IPSS, and urine flow studies to
establish if there is evidence of obstructive voiding. Further tests may be
indicated depending on the patient/history. Other tests include blood test,
urinalysis, PSA, US, flow studies. an cystoscopy.
Describe blood tests with BPH. - ANSWER Blood tests, including renal function
tests, are useful to establish baseline renal function and can help support the
, diagnosis of renal failure/acute kidney injury in someone with chronic high-
pressure retention or acute retention, for example.
Describe urinalysis with BPH. - ANSWER Urine specimen testing can help detect
infection, non-visible haematuria, or metabolic disorders (glycosuria).
Leucocytes and nitrites are common findings with infection; the presence of
proteinuria may point towards nephrological conditions. The American
urological association recommend urinalysis using a dipstick test, further tests
may be requested based on abnormal dipstick findings (culture, etc.).
Describe prostate- specific antigen (PSA) with a patient with BPH. - ANSWER
Prostate-specific antigen testing has been shown to predict prostate volume.
Prostate-specific antigen (PSA) testing should be used with caution, however,
and should not be done routinely in the investigation of BPH. Levels may be
raised in a large range of conditions (large prostate, infection, catheterization,
prostate cancer) and can cause undue anxiety or further unnecessary
investigations for the patient. It is the author's preference to conduct PSA
testing in specific circumstances, i.e., where cancer is suspected (malignant
feeling prostate, metastatic disease suspected) or a previous baseline
established.
Describe ultra sound with BPH. - ANSWER Ultrasound scans are used to look for
evidence of hydronephrosis and are indicated in patients with high residual
volumes or renal impairment. Other indications include suspicion of urinary
tract stones or the investigation of haematuria.
Describe flow studies for a patient with BPH. - ANSWER Urine flow studies are
used to determine the volume of urine passed over time. This can help establish
whether there is objective evidence for obstruction to flow. Urodynamic studies
are used to see how the bladder empties and fills. They can help further assess
patients where the diagnosis is not certain or where a neurogenic/overactive
bladder is suspected (i.e., neurological conditions that may affect the bladder,
flow studies equivocal, diagnosis not clear).
Describe cystoscopy in patients with BPH. - ANSWER Flexible cystoscopy
should be used to investigate red flag symptoms such as visible
haematuria/suspected bladder cancer and can also be used to look for urethral
strictures, which may also result in poor flow/decreased urinary flow studies.
Describe the treatment for BPH. - ANSWER observation
medical therapy
surgery
TURP/TUIP
HOLEP
Urolift
With Accurate Answers
Define benign prostatic hyperplasia. - ANSWER the nonmalignant growth or
hyperplasia of prostate tissue and is a common cause of lower urinary tract
symptoms in men
What are the different ways to describe BPH? - ANSWER Several definitions
exist in the literature when describing BPH. These include bladder outlet
obstruction (BOO), lower urinary tract symptoms (LUTS), and benign prostatic
enlargement (BPE). BPH describes the histological changes, benign prostatic
enlargement (BPE) describes the increased size of the gland (usually secondary
to BPH) and bladder outlet obstruction (BOO) describes the obstruction to flow.
Those with BPE who present with BOO are termed benign prostatic obstruction.
Lower urinary tract symptoms (LUTS) simply describe urinary symptoms shared
by disorders affecting the bladder and prostate (when in reference to men).
LUTS can be subdivided into storage and voiding symptoms. These terms have
largely replaced those historically termed "prostatism."
What causes the development of BPH? - ANSWER The development of benign
prostatic hyperplasia is characterized by stromal and epithelial cell proliferation
in the prostate transition zone (surrounding the urethra), this leads to
compression of the urethra and development of bladder outflow obstruction
(BOO) which can result in clinical manifestations of lower urinary tract
symptoms (LUTS), urinary retention or infections due to incomplete bladder
emptying.
What can happen when BPH is left untreated for long-term? - ANSWER Long-
term, untreated disease can lead to the development of chronic high-pressure
retention (a potentially life-threatening emergency) and long-term changes to
the bladder detrusor (both overactivity and reduced contractility).
How do hormonal effects of testosterone on the prostate tissue cause BPH? -
ANSWER Although they do not cause BPH directly, testicular androgens are
required in the development of BPH with dihydrotestosterone (DHT) interacting
directly with prostatic epithelium and stroma. Testosterone produced in the
testes is converted to dihydrotestosterone (DHT) by 5-alpha-reductase 2 in
prostate stromal cells and accounts for 90% of total prostatic androgens. DHT
has direct effects on stromal cells in the prostate, paracrine effects in adjacent
prostatic cells, and endocrine effects in the bloodstream, which influences both
cellular proliferation and apoptosis (cell death).
,BPH arises as a result of the loss of homeostasis between cellular proliferation
and cell death, resulting in an imbalance favoring cellular proliferation. This
results in increased numbers of epithelial and stromal cells in the periurethral
area of the prostate and can be seen histopathologically
What are some risk factors for BPH? - ANSWER metabolic syndrome, obesity,
hypertension, and genetic factors. Increasing in age drastically increases the
occurrence of BPH.
Describe metabolic syndrome and BPH - ANSWER Metabolic syndrome refers to
conditions that include hypertension, glucose intolerance/insulin resistance,
and dyslipidemia. Meta-analysis has demonstrated those with metabolic
syndrome and obesity have significantly higher prostate volumes. Further
studies looking at men with elevated levels of glycosylated hemoglobin (Hba1c)
have demonstrated an increased risk of LUTS.
Describe the relationship of obesity to BPH. - ANSWER Obesity has been shown
to be associated with increased risk of BPH in observational studies. The exact
cause is unclear but is likely multifactorial in nature as obesity makes up one
aspect of the metabolic syndrome. Proposed mechanisms include increased
levels of systemic inflammation and increased levels of estrogens.
Describe the relationship of genetics to BPH. - ANSWER Genetic predisposition
to BPH has been demonstrated in cohort studies, first-degree relatives in one
study demonstrated a four-fold increase in the risk of BPH compared to control.
These findings have demonstrated consistency in twin studies looking at the
disease severity of BPH, with higher rates of LUTS seen in monozygotic twins.
Describe the patho of BPH. - ANSWER Both the development of lower urinary
tract symptoms and bladder outlet obstruction in men with BPH can be
attributable to static and dynamic components. Static obstruction is a direct
consequence of prostate enlargement resulting in periurethral compression and
bladder outlet obstruction. Here, periurethral compression requires increasing
voiding pressures to overcome resistance to flow; in addition, prostate
enlargement distorts the bladder outlet causing obstruction to flow.
Dynamic components include the tension of prostate smooth muscle (hence the
use of 5-alpha reductase inhibitors to reduce prostate volume and alpha-
blockers to relax smooth muscle). This is explained by decreases in elasticity
and collagen in the prostatic urethra in men with BPH, which may further
exacerbate bladder outlet obstruction due to loss of compliance and increased
resistance to flow and may explain why prostate size alone is not always a
predictor of disease.
Describe the histopathology of BPH. - ANSWER Histological examination
demonstrates that BPH is a hyperplastic process with an increase in cell
number on histology (hyperplasia); these occur both in the periurethral and
,transition zones. Histological studies have demonstrated both glandular and
stromal proliferation. Specifically, periurethral zones demonstrate stromal
nodules, whereas glandular nodular proliferation is seen within the transition
zone.
Describe the lower urinary tract symptoms of a patient with BPH. - ANSWER
Lower urinary tract symptoms can be divided into storage (frequency, nocturia,
urgency) and voiding symptoms (stream, straining, hesitancy, prolonged
micturition) and can help establish other causes of urinary symptoms such as
urinary tract infections/overactive bladder, in addition to determining the site
affected (bladder vs. prostate). Men with BPH are likely to report predominant
symptoms of nocturia, poor stream, hesitancy, or prolonged micturition.
Describe red flags for BPH. - ANSWER Red flags help point to more sinister
causes of urinary symptoms such as bladder/prostate cancer, neurology such
as cauda equina, or chronic high-pressure retention (which can lead to silent
renal failure). The presence of these can be established by asking about visible
haematuria/bone pain/weight loss, neurology, and nocturnal
enuresis/incontinence, respectively.
Describe the physical exam for a patient with BPH. - ANSWER In the elective
setting, the examination should include abdominal examination (looking for a
palpable bladder/loin pain) and examination of external genitalia (meatal
stenosis or phimosis). The examination should then conclude with a digital rectal
examination making a note in particular of the size, shape (how many lobes), and
consistency (smooth/hard/nodular) of the prostate (BPH is characterized by a
smooth enlarged prostate).
Further bedside evaluation includes
-Urine dipstick (rule out other causes such as infection)
-Post-void residual volume (whether the bladder is emptied properly)
-IPSS (international prostate symptom score)
-Frequency-volume chart
The IPSS stratifies patients into three groups on the basis of symptoms. They
are: - ANSWER mild (0-7), moderate (8-19), and severe (20-35). Those with more
severe symptoms are less likely to benefit from conservative or medical
measures.
How is BPH diagnosed? - ANSWER Standard investigation of BPH may include
bedside urine dipstick, post-void residual, IPSS, and urine flow studies to
establish if there is evidence of obstructive voiding. Further tests may be
indicated depending on the patient/history. Other tests include blood test,
urinalysis, PSA, US, flow studies. an cystoscopy.
Describe blood tests with BPH. - ANSWER Blood tests, including renal function
tests, are useful to establish baseline renal function and can help support the
, diagnosis of renal failure/acute kidney injury in someone with chronic high-
pressure retention or acute retention, for example.
Describe urinalysis with BPH. - ANSWER Urine specimen testing can help detect
infection, non-visible haematuria, or metabolic disorders (glycosuria).
Leucocytes and nitrites are common findings with infection; the presence of
proteinuria may point towards nephrological conditions. The American
urological association recommend urinalysis using a dipstick test, further tests
may be requested based on abnormal dipstick findings (culture, etc.).
Describe prostate- specific antigen (PSA) with a patient with BPH. - ANSWER
Prostate-specific antigen testing has been shown to predict prostate volume.
Prostate-specific antigen (PSA) testing should be used with caution, however,
and should not be done routinely in the investigation of BPH. Levels may be
raised in a large range of conditions (large prostate, infection, catheterization,
prostate cancer) and can cause undue anxiety or further unnecessary
investigations for the patient. It is the author's preference to conduct PSA
testing in specific circumstances, i.e., where cancer is suspected (malignant
feeling prostate, metastatic disease suspected) or a previous baseline
established.
Describe ultra sound with BPH. - ANSWER Ultrasound scans are used to look for
evidence of hydronephrosis and are indicated in patients with high residual
volumes or renal impairment. Other indications include suspicion of urinary
tract stones or the investigation of haematuria.
Describe flow studies for a patient with BPH. - ANSWER Urine flow studies are
used to determine the volume of urine passed over time. This can help establish
whether there is objective evidence for obstruction to flow. Urodynamic studies
are used to see how the bladder empties and fills. They can help further assess
patients where the diagnosis is not certain or where a neurogenic/overactive
bladder is suspected (i.e., neurological conditions that may affect the bladder,
flow studies equivocal, diagnosis not clear).
Describe cystoscopy in patients with BPH. - ANSWER Flexible cystoscopy
should be used to investigate red flag symptoms such as visible
haematuria/suspected bladder cancer and can also be used to look for urethral
strictures, which may also result in poor flow/decreased urinary flow studies.
Describe the treatment for BPH. - ANSWER observation
medical therapy
surgery
TURP/TUIP
HOLEP
Urolift
