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Q1: DRE (2 min)
"A 70-year-old man has LUTS. How does DRE help?"
- BPH: smooth, symmetrically enlarged, rubbery, preserved median sulcus[1][2]
- Cancer: hard, irregular, craggy, loss of sulcus
- Prostatitis: tender, boggy, warm
- Also assess anal tone, rectal mucosa, check for faecal impaction[1][2]
Q2: Medical therapy (3 min)
"Describe the two classes of drugs for BPH."
- Alpha-1-blockers (tamsulosin): relax prostatic smooth muscle (dynamic), rapid onset (days), side effects: dizziness, postural hypotension, floppy iris syndrome, retrograde ejaculation[1][2]
- 5-ARIs (finasteride): block DHT, shrink gland (static), slow (6 months), side effects: reduced libido, ED, gynaecomastia, and a PSA fall of about 40 percent on finasteride (never read an unadjusted PSA)[1][2]
- Combination for larger prostates (MTOPS trial, 66% reduction in progression)[1][2]
Q3: TURP (3 min)
"Describe the TURP procedure and its complications."
- Transurethral resection with diathermy loop through resectoscope[1][2]
- Glycine 1.5% irrigation (non-electrolyte for monopolar diathermy)[1][2]
- Resect transition zone tissue in chips, create channel
- Chips sent for histology (incidental cancer in 5-10%)
- Complications: retrograde ejaculation (65-75%, commonest), bleeding (2-5%), incontinence (1-3%), stricture (3-5%), TURP syndrome (1-2%, hyponatraemia from glycine absorption)[1][2]
Q4: Acute retention (2 min)
"A patient cannot void and has a painful palpable bladder. What do you do?"[1][2]
- Immediate urethral catheterisation (12-14 Fr Foley)
- Check U&Es (post-renal AKI)
- Start tamsulosin 0.4 mg OD
- TWOC (trial without catheter) after 1-3 days
- If fails: re-catheterise, plan TURP
References3ShowHide
- [1]Lerner LB, McVary KT, Barry MJ, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline J Urol, 2021.PMID 34384237
- [2]McConnell JD, Roehrborn CG, Bautista OM, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia N Engl J Med, 2003.PMID 14681504
- [3]McConnell JD, Bruskewitz R, Walsh P, et al. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia N Engl J Med, 1998.PMID 9475762