BPH – Case Studies & FAQs

Dr Clarence Lei Chang Moh, Consultant Urologist

clarencelei@gmail.com

BORNEO REGIONAL UROLOGY WORKSHOP, Kota Kinabalu, 9-10 July 2011

Mr C C K, 76 years old, retired Govt teacher(P.B.L. case scenario)

• 16.12.09: Referred by nephrologist for intermittent giddiness, “possibly due to prostate medication”.

• Nocturia 3x and consulted family doctor. PSA 0.7 (31.8.08)

• Started on “Hytrin 2mg ON” • Patient seen in Cardiac Clinic, SGH for ? irregular

heart rhythm and on Cardiprin.• Managed to get Cardiologist to continue urological

medication and was given Terazosin 2 mg (RM1 vs 70s).

What are the causes of nocturia?(Dr Lei N2X)

1. Prostate

Women also reports nocturia

- give prostate medications ?

What are the causes of nocturia?(Dr Lei N2X)

1. Prostate problem - incomplete bladder emptying, requiring multiple voiding:

2. Bladder problem:

- OAB, overactive bladder, treat with anti-cholinergic

- Decreased bladder compliance with age: less fluid pm

Bladder irritation:

(a) UTI: urine test, antibiotics

3 . Volume: nocturnal polyuria due to:

(a) Diabetes mellitus (up to 20% - MAJOR problem)

(b) Heart failure: lasix am, nap pm

(c) “Diabetes insipidus” Polyuria – Minirin (taxi driver – CPM)

4. Brain: Poor sleep/anxiety

5. Combination !! – treat one by one

Assessment of nocturia, given prostate medications

• If prostate is causing obstruction, poor urine flow.• urine flow will be good only vol >150 cc. • (the patient said his urine flow is very good in the

morning with some urgency)

• Patient probably did not have BOO from prostate and Hytrin or similar inappropriate. Moreover, the alpha-blocker may contribute the giddiness.

obstructed

FOC – at campaigns

Do u observe others? : flow/penis

What further specialised investigations?

1. PSA, (PSA> 1.5 = enlarged = Avodart). • Uroflowmetry, Urology Clinics,

(max 15 ml/s VV 150 ml)

PSA 0.15

HPCRAUR

Other α-blockers

• α blocker - prazosin 1-2 mg ON, bd (also BP)• selective α1 blocker

– Terazosin 1- 2- 5mg ON (Titrate!) (“Hytrin”)– Doxazosin XL 4 mg ON (“Cardura”)

• Uroselective α1 blocker– Tamsulosin (“Harnal”)– Alfuzosin XL (“Xatral”)

Barkin J. Canadian Journal of Urology.2008;15(6) 4353-4358

Urine retention

• (case of Australian Immigration; pc, palpable bladder, hydro)

A.Catheter? in /out/admit

B.TWOC

C.? TWOC with meds

D.Catheter admit; TURP

E.Catheter TURP 1 week

Cx BPH: how common?• Thirds: stable, better, progress

• Retention: acute, chronic (detrusor failure)

• UTIs

• Stones

• OAB, overactive

• Obstructive Uropathy

• Admission: fever, bleed, diuresis or hydro

• OPERATION (9%)

Ball AJ, Fenelay RCL, Abrams PH: The Natural History of Prostatism. Brist J Urol, 53: 613-616, 1981

Surgery : gold standard is TURP (etc)

Barkin J. Canadian Journal of Urology.2008;15(6), 4353-4358.AUA guidelines. J. Urol. 2003, 170, 530-547

Conclusion: which drug(s) to use?

Start -blocker (e.g. Harnal) for 1-2 weeks, add AREI if prostate enlarged (e.g. Avodart)

Start together (if finance alright)Change to alternative cheaper -blockerStart AREI only, if s/effects -blocker (BP low)Stop -blocker after 6 months, (77%, SMART1 study)Add anti-cholinergic anytime if bothersome OAB, (e.g.

Vescicare)PDE5 I eg Viagra, Cialis, Levitra, ZydenaTestosterone

Addon Vesicare to Harnal safe. J Urol 2009; 182: 2825-2830

Alpha blocker and Ureteric stones

• MET – medical expulsive therapy

• Tamsulosin & Ureter BJUI 2008 101 1061-2

Q & A Session 3

? Prostatitis, organisms & antibiotics

? Can a decrease of PSA with Avodart indicate no CaP ?

? Trial off catheter in AUR with no treatment?

? PIN, 1-3

? TURP complications, incl. ED

?

?

SELECT Trial

Selenium Vit E Placebo Combination

men, >55 yrs, n = 35,533

2001 - 4; No use

JAMA 2008; 301: 39-51

P C P T

Prostate Cancer Prevention Trial

Finasteride, n = 18882, 7 yrs.

Decrease Ca 24.4% to 18.4%

NEJM 2003; 349: 215-224

REDUCE

Reduction Dutasteride Cancer Events

n = 8231, 4 yrs

Reduce biopsy cancers from 11.8% to 9.1%

Andriole J Urol 2004; 172: 1314-7, AUA abstract 2009

Thank you