kashifuddin qayoom soomro assistant professor department of urology liaquat university of medical...
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Kashifuddin Qayoom SoomroKashifuddin Qayoom Soomro
Assistant ProfessorAssistant ProfessorDepartment of UrologyDepartment of Urology
Liaquat University of Medical & Health Sciences Liaquat University of Medical & Health Sciences JamshoroJamshoro
BPH – From Diagnosis To Treatment Strategies in GP Practice
The most common benign tumor in The most common benign tumor in men.men.
Half of all men over the age of 60 Half of all men over the age of 60 will develop an enlarged prostatewill develop an enlarged prostate
By the time men reach their 70’s and By the time men reach their 70’s and 80’s, 80% will experience urinary 80’s, 80% will experience urinary symptomssymptoms
n
n
BPH and prevalenceBPH and prevalence
BPH is a very frequent BPH is a very frequent conditioncondition
in ageing men in ageing men
0%
20%
50%
90%
< 30 years 41-50 years 51-60 years > 80 years
Prevalence of BPH
What causes BPH?What causes BPH?
BPH is part of the BPH is part of the natural aging process, natural aging process, like getting gray hair or like getting gray hair or wearing glasseswearing glasses
BPH BPH cannotcannot be be
preventedprevented
BPH BPH cancan be treated be treated
n
n
The lower urinary tract The lower urinary tract symptoms (LUTS)symptoms (LUTS)
BPHBPH
Bladder Outlet Obstruction (BOO)Bladder Outlet
Obstruction (BOO)
Impaired detrusorcontractility
Impaired detrusorcontractility
Involuntarybladder
contraction
Involuntarybladder
contraction
• Voiding symptoms- hesitancy
- weak stream
- prolonged voiding
- post voiding dribbling
- feeling of incomplete emptying
• Decreased flow rates
• Post void residual urine
• Voiding symptoms- hesitancy
- weak stream
- prolonged voiding
- post voiding dribbling
- feeling of incomplete emptying
• Decreased flow rates
• Post void residual urine
• Storage symptoms- urge
- frequency
- nocturia
- urge incontinence
• Storage symptoms- urge
- frequency
- nocturia
- urge incontinence
BPH/LUTS is largely BPH/LUTS is largely undertreatedundertreated
2
11
34
4
19
45
7
26
48
0
20
40
60
80
100
50 - 59 60 - 69 70 - 79
Percentage of men who receive medical treatment for their LUTS by LUTS severity
LUTS
Age
Rosen et al. Eur Urol 2003; 44: 637- 49
The Diagnosis The Diagnosis of BPHof BPH
The patient’s initial The patient’s initial evaluationevaluation
The basic evalution should be done on every patient presenting to a health care provider with LUTS: Medical history Assessment of symptoms
and bother Physical examination (DRE) Urinalysis Serum Prostate-Specific Antigen
(PSA)* Frequency-Volume Chart (to differentiate
between nocturia and polyuria)
*not in all patients
The medical history of the The medical history of the patientpatient
Nature and duration of LUTS
Previous surgical procedures
General health issues, sexual function history
Medications currently taken bythe patient
The patient’s fitness for possible surgical procedures or other treatments
The International Prostate The International Prostate Symptom Score (IPSS)Symptom Score (IPSS)
The I-PSS is based on the answers to 7 questions The I-PSS is based on the answers to 7 questions concerning urinary symptoms.concerning urinary symptoms.
Each question is assigned points from 0 to 5 indicating Each question is assigned points from 0 to 5 indicating increasing severity.increasing severity.
The total score can therefore range from 0 to 35 The total score can therefore range from 0 to 35 (asymptomatic to severely symptomatic).(asymptomatic to severely symptomatic).
MildMild 0-70-7
ModerateModerate 8-198-19
SevereSevere 20-3520-35
Patient name:Patient name:DateDate
1. Incomplete emptying1. Incomplete emptyingOver the past month, how oftenOver the past month, how oftenhave you had a sensation of nothave you had a sensation of notemptying your bladder completelyemptying your bladder completelyafter you finish urinating?after you finish urinating?
2. Frequency2. FrequencyOver the past month, how often Over the past month, how often have you had to urinate again lesshave you had to urinate again lessthan two hours after you finishedthan two hours after you finishedurinating?urinating?
3. Intermittency3. IntermittencyOver the past month, how often Over the past month, how often have you found you stopped andhave you found you stopped andstarted again several times when started again several times when you urinated?you urinated?
Less than1 time in 5
Not at all Less than half in the
time
About half the
time
More than half the
time
Almostalways
0 1
0
0
1
1
2
2
2
3
3
3
4
4
4
5
5
5
The International Prostate The International Prostate Symptom Score (1)Symptom Score (1)
Patient name:Patient name:DateDate
4. Urgency4. UrgencyOver the past month, how often have you Over the past month, how often have you found it difficult to postpone urination?found it difficult to postpone urination?
5. Weak stream5. Weak streamOver the pas month, how often haveOver the pas month, how often haveyou had a weak urinary stream?you had a weak urinary stream?
6. Straining6. StrainingOver the past month, how often haveOver the past month, how often haveyou had to push or strain to begin to you had to push or strain to begin to urinate?urinate?
7. Nocturia7. NocturiaOver the past month, how many times Over the past month, how many times did you most typically get up to urinate did you most typically get up to urinate from the time you went to bed until the from the time you went to bed until the time you got up in the morning?time you got up in the morning?
Less than1 time in 5
Not at all Less than half in the
time
About half the
time
More than half the
time
Almostalways
0 1
0
0
1
1
2
2
2
3
3
3
4
4
4
5
5
5
0 1 2 3 4 5
The International Prostate The International Prostate Symptom Score (2)Symptom Score (2)
Patient name:Patient name:DateDate
1. If you were to spend the rest1. If you were to spend the restof your life with your urinaryof your life with your urinarycondition just the way it is now, condition just the way it is now, how would you feel about that?how would you feel about that?
Pleased Delighted Mostly satisfied
Mixedabout
equally satisfied
and dissatisfied
Unhappy Terrible
0 1 2 3 4 5
BOTHER SCORE (BS) =
The bother score (IPSS 8th The bother score (IPSS 8th question)question)
Disease specific quality of life Disease specific quality of life and sexual functionand sexual function
No recommended questionnaire in routine No recommended questionnaire in routine practicepractice
Sexual function questionnaires used Sexual function questionnaires used exclusively in clinical trials (IIEF, DAN-exclusively in clinical trials (IIEF, DAN-PSSsex, BSFI, MSHQ…) PSSsex, BSFI, MSHQ…)
The physical examinationThe physical examination
1. Abdominal examination
rule out other possible urinary or rectal conditions
2. Digital Rectal Examination(DRE)
fundamental method for assessing the shape and the volume of the prostate
UrinalysisUrinalysis
Standard examination for the detection of:Standard examination for the detection of:
- Haematuria,- Haematuria,
- Proteinuria,- Proteinuria,
- Pyuria, - Pyuria,
4-5% of men with microscopic haematuria will be 4-5% of men with microscopic haematuria will be found to have a cancer or other urological disease found to have a cancer or other urological disease within the first 3 years following the test.within the first 3 years following the test.
Serum Prostate-Specific Serum Prostate-Specific Antigen (PSA)Antigen (PSA)
Measurement recommended for patients with at Measurement recommended for patients with at least 10-year life expectancy and for whom least 10-year life expectancy and for whom knowledge of the presence of prostate cancer knowledge of the presence of prostate cancer would change managementwould change management
PSA is also a proxy of prostate size but its PSA is also a proxy of prostate size but its variability is high. Recent studies suggest that it variability is high. Recent studies suggest that it may be used to predict the risk of AUR and may be used to predict the risk of AUR and BPH-related surgery.BPH-related surgery.
Frequency - volume chartFrequency - volume chart
Measurement useful when nocturia is the Measurement useful when nocturia is the predominant symptompredominant symptom
To identify patients with nocturnal polyuria To identify patients with nocturnal polyuria excessive fluid intakeexcessive fluid intake
BPH TreatmentsBPH Treatments
1. Provide rapid and sustainedrelief of symptoms.
2. Act on the course of thedisease by preventing long-term complications.
3. Respect patients’ Quality of Life and sexual function.
Treatment objectivesTreatment objectives
The BPH patient is basically The BPH patient is basically offered 3 treatment options:offered 3 treatment options:
SurgerySurgeryWatchful WaitingWatchful Waiting
Medical TreatmentMedical Treatment
The patient is instructed on behavioural techniques to reduce symptoms (reduction of fluid intake at bedtime, reduction of alcohol and caffeine consumption…).
The patient’s symptoms and clinical course should be monitored, usually annually.
Definition of watchful waitingDefinition of watchful waiting
Indications of watchful Indications of watchful waitingwaiting
Uncomplicated BPHUncomplicated BPH
Symptoms not bothersome (usuallySymptoms not bothersome (usuallyIPSS ≤7)IPSS ≤7)
Symptoms significantly bothersomeSymptoms significantly bothersomebut after being informed of various but after being informed of various treatment options and their consequences, treatment options and their consequences, the patient chooses watchful waitingthe patient chooses watchful waiting
Indications of medical Indications of medical treatmenttreatment
Uncomplicated BPHUncomplicated BPH
Symptoms are bothersome (usually Symptoms are bothersome (usually IPSS>7) and after being informed of IPSS>7) and after being informed of various treatment options and their various treatment options and their consequences, the patient chooses consequences, the patient chooses medical treatmentmedical treatment
There are 2 pharmacological There are 2 pharmacological classes used in BPHclasses used in BPH
1-blockers1-blockers5-reductase inhibitors5-reductase inhibitors
The 2 components of BOOThe 2 components of BOO
Dynamic Component
Increase inprostate bulk
Increase insmooth muscle tone
Normal Hyperplastic
Static Component
By inhibiting the production of DHT, they are expected to reduce the size of the prostate.
55-reductase inhibitors act on-reductase inhibitors act onthe static component of BOOthe static component of BOO
But …But …
Delayed onset of actionDelayed onset of action Need 6 to 12 months to significantly improve Need 6 to 12 months to significantly improve
LUTSLUTS Less effective than α1-blockade on LUTSLess effective than α1-blockade on LUTS
Improve IPSS of 3 to 4 pointsImprove IPSS of 3 to 4 points More effective for enlarged prostates More effective for enlarged prostates
(> 40g)(> 40g)
They are sparse in the bladder body
11-receptors are abundant in the-receptors are abundant in the
bladder neck, prostate and urethrabladder neck, prostate and urethra
11-blockers-blockers are expected to reduce the sympathetic tone of the
prostate and the urethra.
11-blockers act on the dynamic -blockers act on the dynamic
component of BOOcomponent of BOO
11-blockers may have local-blockers may have local
but also systemic effectsbut also systemic effects
Prostate Urethra
Bladder Neck
Prostate Urethra
Bladder Neck
Outflowresistance
Outflowresistance
FlowRates
FlowRates
VoidingSymptoms
VoidingSymptoms
Residual Urine
Residual Urine
Filling Symptoms
Filling Symptoms
BladderBladder
Blood vesselsBlood vessels
BladderInstability
BladderInstability
Blood Pressure
Blood Pressure
Postural Hypotension
Dizziness
Postural Hypotension
Dizziness
URINARY TRACT EFFECT
SYSTEMIC EFFECT
Uroselectivity is the capacity to Uroselectivity is the capacity to achieve more local than systemic achieve more local than systemic
effectseffects
Uroselective (new generation)
1-blockers mainly effective on the lower
urinary tract
Uroselective (new generation)
1-blockers mainly effective on the lower
urinary tract
Non-uroselective(old generation)
1-blockers primarily developed for the
treatment of hypertension
Non-uroselective(old generation)
1-blockers primarily developed for the
treatment of hypertension
New generation (uroselective) New generation (uroselective) 11-blockers-blockers
Terazosin (HYTRIN)DoxazosinAlfuzosin
Tamsulosin
Recent molecules
Few cardiovascular & CNS side effects
1Marks et al. Urology 2003, 62, 888-8932Lepor Urology 1998, 51, 892-9003AUA Practice Guidelines Committee, J.Urol 2003, 170, 530-547
Benefits of Benefits of 11-blockers in BPH-blockers in BPH Rapid onset of action Rapid onset of action
From the first dose on peak flow rate for From the first dose on peak flow rate for terazosin ( Hytrin ), alfuzosinterazosin ( Hytrin ), alfuzosin1 1 and tamsulosinand tamsulosin22, ,
From the first days on LUTSFrom the first days on LUTS Best monotherapy for relief of LUTSBest monotherapy for relief of LUTS33
Improvement of IPSS of 4 to 6 pointsImprovement of IPSS of 4 to 6 points Effective irrespective of prostate sizeEffective irrespective of prostate size Improve quality of life and respect sexual Improve quality of life and respect sexual
functionfunction
1McNeill et al. Urology 2005, 65, 83-902McConnell et al. NEJM 2003, 349, 2387-983Roehrborn et al., BJU Int 2006, 97, 734-741
Benefits of Benefits of 11-blockers in BPH-blockers in BPH
Facilitate catheter removal with return to normal Facilitate catheter removal with return to normal voiding in men with AURvoiding in men with AUR11
Reduce BPH progressionReduce BPH progression:: Terazosin ( Hytrin ), Alfuzosin and doxazosin do not Terazosin ( Hytrin ), Alfuzosin and doxazosin do not
prevent the occurrence of AURprevent the occurrence of AUR2-32-3.. However, Terazosin ( Hytrin ) alfuzosin and doxazosin However, Terazosin ( Hytrin ) alfuzosin and doxazosin
significantly reduce deterioration of LUTS compared significantly reduce deterioration of LUTS compared with placebowith placebo2-32-3. .
Complicated BPHComplicated BPH
Bladder stones Bladder stones Recurrent haematuriaRecurrent haematuria Acute Urinary RetentionsAcute Urinary Retentions Damage to kidneys Damage to kidneys Urinary tract infections Urinary tract infections
Surgical Surgical TreatmentsTreatments
Open prostatectomyOpen prostatectomy Transurethral Resection of the Prostate Transurethral Resection of the Prostate
(TURP)(TURP) Transurethral Incision of the Prostate Transurethral Incision of the Prostate
(TUIP)(TUIP) Transurethral Microwave Transurethral Microwave
Thermotherapy (TUMT)Thermotherapy (TUMT) Transurethral vaporization of the Transurethral vaporization of the
prostate (TUVP)prostate (TUVP) Transurethral needle ablation of the Transurethral needle ablation of the
prostate (TUNA)prostate (TUNA)
CONCLUSIONCONCLUSION
Every male > 50 yrs of age should be Every male > 50 yrs of age should be evaluatedevaluated
To exclude possibility of Ca prostate To exclude possibility of Ca prostate
To exclude complication resulting from To exclude complication resulting from BPHBPH
To improve the quality of life of patients To improve the quality of life of patients having LUTS with medical therapyhaving LUTS with medical therapy
ThanksThanks
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