BPH AND LUTSSalman Bangash 2014-081

BPH-LUTS

• Benign prostatic hyperplasia is the histological pattern of the prostate, characterized by proliferation of smooth muscle and epithelial cells within the prostatic transition zone. This may lead to prostatic enlargement.

• Lower urinary tract symptoms refer to storage and/or voiding disturbances.

• BPH-LUTS refers to bothersome lower urinary tract symptoms linked to the prostate.

• Not all men with BPH have LUTS and not all patients with LUTS have BPH.

BPH

• It is considered a normal part of aging in men and is hormonally dependent on testosterone and DHT production.

• 50% of men develop BPH by age 60 years and 90% by age 85 years.

BPH

• Patients with mild LUTS can be treated medically.

• TURP ( transurethral resection of the prostate ) is the standard procedure for relieving bladder outlet obstruction secondary to BPH.

PROSTATE

• It is a walnut sized gland and is a part of the male reproductive system

• Located anterior to the rectum and distal to the urinary bladder.

• It is connected directly with the penile urethra hence it’s a conduit between the bladder and urethra.

• BPH originates in the Transition zone which surround the urethra.

PROSTATE

PROSTATE

• Main function of the prostate is to secrete and alkaline fluid that compromises 70% of the seminal volume.

• Secretions produce lubrication and nutrition for the sperm.

• Alkaline fluid helps neutralize the acidic vaginal environment.

RISK FACTORS

• Obesity

• Lack of physical activity

• Erectile dysfunction

• Increasing age

• Family history of BPH

EVALUATION OF PATIENTS

• Medical history

• Directed physical exam

• Urinalysis

• PSA testing

• Symptom assessment

MEDICAL HISTORY

• Nature and duration of symptoms

• Fluid intake – amount and types of fluid

• Sexual history

• Comorbid conditions

• Prior and current illness

• Prior surgery and trauma

• Current medications

• Any previous treatments.

CLINICAL MANIFESTATIONS

• Urinary frequency

• Urgency

• Nocturia

• Hesitancy

• Incomplete emptying of bladder

• Straining

• Dribbling

SEXUAL HISTORY

• Sexual history is important because studies have identified LUTS as an independent risk factor for erectile dysfunction and ejaculatory dysfunction.

EXAMINATION

• DIGITAL RECTAL EXAM --- Evaluate prostate for size, consistency,

shape and abnormalities suggestive of prostate cancer (such as nodules or asymmetry)

• Assess suprapubic area to rule out bladder distention

• Evaluate overall motor and sensory function of the perineum and lower limbs

COMPLICATIONS

• Urinary retention

• Renal insufficiency

• Recurrent UTI

• Gross hematuria

• Bladder calculi

• Renal failure or Uremia

URINALYSIS

•Dipstick urinalysis should be performed in all BPH-LUTS patients to rule out other diagnoses that may cause LUTS.

•Abnormal/borderline urinalysis results should be repeated and/or followed with a urine culture

URINALYISIS

Urinalysis result Possible diagnosis

HematuriaKidney stonesBladder cancer

Pyuria or nitratesUTI

Urethral stricture

Proteinuria Underlying renal disease

Glucosuria diabetes

PSA TESTING

• BPH does not cause prostate cancer, however men at risk of BPH are also at risk of developing prostate cancer.

• It is a sensitive screening test for prostate volume.

• Men at age 50 who are expected to live at least 10 more year.

• 45 years in men who are at high risk ( African American’s or close relative with prostate cancer )

ULTRASONOGRAPHY

• Help determine prostate and bladder size and degree of hydronephrosis in patients with urinary retention.

• Transrectal ultrasonography is recommended in selected patients to determine the dimensions and volume of the prostrate.

CYSTOSCOPY

• It is indicated in patients whom a malignancy or foreign body is suspected.

INTERNATIONAL PROSTATE SYMPTOM

SCORE

1-7 = mild 8-19 = moderate 20-35 = severe

AMERICAN UROLOGICAL ASSOCIATION

TREATMENT FLOW CHART

MEDICAL THERAPY• Alpha-blockers are a first-line option for men with

symptomatic bother who desire treatment

• 5ARI’s are an effective option for symptomatic patients with demonstrable prostatic enlargement

• Combination alpha-blocker and 5-ARI therapy improves symptom score and peak urinary flow vs. monotherapy; appropriate for patients with LUTS associated with prostatic enlargement

• A PDE5 inhibitor can be used once-daily in men with moderate to severe symptoms and bother, to effectively reduce symptoms of BPH-LUTS while maintaining sexual function

• Phytotherapy is not recommended by the CUA

ALPHA BLOCKERS• Selective antagonist of α1-adrenoceptors located in:

• Prostate • Prostatic capsule • Bladder base • Bladder neck • Prostatic urethra

• Help relax smooth muscle in the bladder neck and prostate; allow urine to flow more freely

• Selective and non-selective alpha-blockers exist

• Non-selective alpha-blockers are not commonly used for BPH-LUTS

ALPHA BLOCKERS

• First line options include

• Equal clinical effectiveness for LUTS secondary to BPH • Do not alter the natural progression of the

disease • Choice of agent should depend on

comorbidities, side effect profile and tolerance

Selective :- Alfuzosin Tamsulosin Silodosin

Non selective: Doxazosin Terazosin

SIDE EFFECTS

• Retrograde ejaculation

• Erectile dysfunction

• Asthenia •

• Dizziness

• Orthostatic hypotension

• Nasal congestion

5-ALPHA REDUCTASE INHIBITORS

• Indicated as first-line therapy for men with enlarged prostates:• Finasterideinhibits 5α-reductase Type 2 (prostate) • Dutasterideinhibits 5α-reductase Type 1 AND 2 (liver,

skin and prostate)

• Blocks the conversion of testosterone to DHT (responsible for prostate growth)

• Treatment with 5-ARIs reduce:• Prostate size • PSA • Long-term risk of acute urinary retention • Need for surgery

SIDE EFFECTS

• Reduced libido

• Erectile dysfunction

• Decreased ejaculate volume

• Breast tenderness

COMBINATION THERAPY

• Combined alpha-blocker and 5-ARI therapy is effective for LUTS associated with prostatic enlargement

• Improves symptom score and peak urinary flow greater than either monotherapy option

• Delays symptomatic disease progression

• Decreased risk of urinary retention and/or prostate surgery

PDE5 INHIBITORS

• Promote smooth muscle relaxation.

• Improve LUTS.

• Improves quality of life.

• Effective in men with or without erectile dysfunction.

• Tadalafil is the only approved PDE5 inhibitor for BPH-LUTS.

SIDE EFFECTS

• Headache

• Facial flushing

• Dyspepsia

TREATMENT RESPONSE

Drug classTime for symptom

improvement

Alpha blockers 2-4 weeks

5 alpha reductase inhibitors Atleast 6 months

PDE5 inhibitors 4 weeks

CASE SCENARIOS

Case description Recommendation

Moderate – severe bother (PSA 1.3ng/ml)

Alpha blocker

Diabetes Alpha blocker

hypertension Alpha blocker

Erectile dysfunction Alpha blocker or PDE5

Enlarged prostate + PSA > 1.5ng/ml

5-ARI

Enlarged prostate + PSA > 1.5ng/ml + ED

5-ARI and/or PDE5

Bothersome sexual side effects with α-blocker or 5-ARI PDE5

SURGICAL TREATMENT

• Renal insufficiency

• LUTS complications

• Patient requests surgical treatment

• Medication is ineffective

• Medication side effects are intolerable

PROSTATE SIZE

Very large ( 80-100g )

Large ( 30-80g ) Small ( <30g )

Open prostatectomy TURP TURP

Laser prostatectomy-holium

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Laser prostatectomy-holium

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Minimally Invasive - TUMT- TUNA

RISKS OF SURGERY

• Excessive bleeding requiring blood transfusion

• TUR syndrome

• Permanent sexual side effects: • Retrograde ejaculation • Erectile dysfunction (less common)

• Urinary tract infections

• Urinary incontinence

• Need for retreatment: • Prostate regrowth • Bladder/urethral strictures