Download - Benign Prostatic Hyperplasia (BPH and LUTS)
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
-greenlight
Laser prostatectomy-holium
-greenlight
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