thursday school december 11, 2014 richard hoffman, md, mph

Benign Prostatic Hyperplasia

Thursday SchoolDecember 11, 2014Richard Hoffman, MD, MPH

Case

59 y/o Hispanic male with HTN (amlodipine), HLD (simvastatin), and allergic rhinitis (nasal steroid) presents to clinic c/o increasing urinary hesitancy, dribbling, and nocturia over the past 6 months. Based on these lower urinary tract symptoms, you suspect BPH.

What else could it be?

Differential diagnoses

Urinary tract infection (prostatitis, cystitis)

Prostate cancer Bladder cancer Urethral stricture/bladder neck

contracture Bladder calculi Neurogenic bladder

Parkinson CVA Diabetes (also glycosuria)

How do you evaluate him?

How do you evaluate him?

AUA symptom index? Digital rectal examination? Urinalysis? Post-void residual urine volume? Peak urinary flow? Basic metabolic panel? PSA? Renal ultrasound?

Prostate gland

Benign prostatic hyperplasia

Benign proliferation of stromal and epithelial tissue Obstruction▪ Static (bulk enlargement)▪ Dynamic (smooth muscle)

Irritation▪ Bladder instability

AUA Symptom Index

Obstructive symptoms Incomplete emptying Weak stream Intermittency Straining

Irritative symptoms Frequency Urgency Nocturiahttp://www.urologyhealth.org/_media/_pdf/AUA%20Symptom%20Score.pdf

http://www.urologyhealth.org/_media/_pdf/AUA%20Symptom%20Score.pdf

http://www.urologyhealth.org/_media/_pdf/AUA%20Symptom%20Score.pdf

AUA Symptom Index

How often in the past month (all but nocturia)? Scored from 0 (never) to 5 (almost always)

Nocturia Scored from 0 (never) to 5 (5 or more

times) Scoring

0 to 7: mild 8 to 19: moderate 20 to 35: severe

Digital rectal examination

Prostate enlargement Prostate cancer

Nodule, induration, asymmetry Rectal sphincter tone

Urinalysis

Bacteria White blood cells Glucose Red blood cells

Serum creatinine

Bladder outlet obstruction Renal disease

Optional

Post-void residual urine volume Suspected obstruction▪ Bladder scan

Peak urinary flow rate Low rates (< 15 ml/s) could be due to

obstruction or decompensated bladder

Optional

PSA Informed decision making Abnormal DRE, risk factors

Renal ultrasound Elevated creatinine, UTI

Case

DRE normal Urinalysis negative Creatinine normal AUA symptom score = 7

How do you treat him?

Behavioral (watchful waiting) Medications

5-ARI Alpha blockers Anti-cholinergics PDE-5 inhibitors

How do you treat him?

Preference sensitive; however, behavioral appropriate initial approach for mild to moderate symptoms Limit fluid intake before bedtime,

especially caffeine and alcohol Double voiding before going to bed Avoid medications: anticholinergics,

antihistamines, alpha agonists, diuretics

Medical options

Alpha blockers 5-alpha reductase inhibitors Anticholinergics Phosphodiesterase-5 inhibitors Herbal therapies

When to initially consider surgery

When to initially consider surgery

Urinary retention Renal insufficiency Recurrent infections Bladder stones Hematuria

When to eventually consider surgery

Symptoms progressing/bothersome on medical management

Medical management not tolerated

Surgical options

TURP Open prostatectomy TUIP TEVAP TUNA Laser coagulation/prostatectomy TUMT

Surgical options

TURP is gold standard treatment Improves symptom scores by 10

points(70%) Reduces treatment failure vs. watchful

waiting by 52% (8% vs. 17%)▪ Death, intractable retention, residual urine

volume > 350 ml, bladder stone, incontinence, AUA sx score ≥ 24, doubling of creatinine

Surgical options

TURP Requires hospitalization, catheter Complications▪ Bleeding, infection, stricture, TUR syndrome,

retrograde ejaculation

Alpha blockers

FDA-approved drugs Terazosin, Doxazosin, Tamsulosin,

Alfuzosin, Silodosin Titrate terazosin, doxazosin

Indication Moderate/severe symptoms Small prostate (< 40 gms)

Alpha blockers

Mechanism of action Relaxes smooth muscle in bladder neck,

prostate Effective within 1-2 weeks

First-line agent Benefits

Improves symptom scores by 30 to 40%

Alpha blockers

Side effects Hypotension/dizziness ▪ Less with tamsulosin

Asthenia Floppy iris syndrome (cataract surgery)▪ Tamsulosin

Nasal congestion Headache

Case

A patient returns to clinic. He was taking terazosin 15 mg for BPH, but was just summering in Alaska. His medications did not reach him and he ran out 2 months ago. His lower urinary tract symptoms are quite bothersome.

Do you…

Restart terazosin at same dose Restart terazosin at low dose, titrate Prescribe tamsulosin

5-alpha-reductase inhibitors

FDA-approved drugs Finasteride Dutasteride

Indication Moderate/severe symptoms Not tolerating alpha blocker Large prostate (> 60 gm)▪ Can combine with alpha blocker


Mechanism of action Blocks conversion of testosterone to

dihydrotestosterone (prostate, hair follicles)

Guevedoces

Isolated village of Dominican Republic

Children appearing to be girls turned into men at puberty “pseudohermaphrodites”

Imperato-McGinley J. Science 1974;186:1213

Guevedoces

Prostate remains small No prostate cancer No hairline recession5-alpha-reductase deficiency


Benefits Reduces urinary symptoms by ~20% Reduces risk of surgery, urinary

retention especially when combined with alpha blocker

Side effects Erectile dysfunction Decreased libido Gynecomastia


Prostate cancer Reduces PSA by 2-fold Reduces risk for cancer by 25% Increase risk for high-grade cancers FDA would not allow manufacturers to

market for cancer prevention and issued warning “be aware that 5-ARIs may increase the risk of high-grade prostate cancer”

Anticholinergics

Treat overactive bladder in BPH Combined with α-blocker > α-blocker

Approved drugs Tolterodine, oxybutinin

UpToDate®: consider for men with irritative symptoms, without elevated PVR

I would refer to GU

PDE-5 inhibitors

Treat BPH with ED Medications

Sildenafil, vardenafil, tadalafil UpToDate®: consider for men with

ED and mild/moderate BPH Modest evidence, most placebo-

controlled, not better than alpha blocker

Herbal therapies

References

Update on AUA guideline on the management of benign prostatic hyperplasia. McVary KT et al. J Urol 2011;185:1793.

The American Urological Association symptom index for benign prostatic hyperplasia. Barry MJ, et al. J Urol 1992;148:1549.

A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. Wasson JH, et al. NEJM 1992; 332:75.

The influence of finasteride on the development of prostate cancer. Thompson IM, et al. NEJM 2003;349:215.

Effect of dutasteride on the risk of prostate cancer. Andriole GL, et al. NEJM 2010; 362:1192.

Finasteride for benign prostatic hyperplasia. Tacklind J. et al. Cochrane Database Syst Rev 2010;Oct 6 (10): CD006015]

Terazosin for benign prostatic hyperplasia. Wilt TJ, et al. Cochrane Database Syst Rev 2002; (4): CD003851

References

Terazosin for benign prostatic hyperplasia. Wilt TJ, et al. Cochrane Database Syst Rev 2002; (4): CD003851

Effect of increasing doses of saw palmetto extract on lower urinary tract symptoms: a randomized trial. Barry MJ, et al. JAMA 2011; 306:1344.

Laser prostatectomy for benign prostatic obstruction. Hoffman RM, et al. Cochrane Database Syst Rev 2004; (1):CD001987

Microwave thermotherapy for benign prostatic hyperplasia. Hoffman RM, Langsjoen J, et al. Cochrane Database Syst Rev 2012; Sep 12;9:CD004135.

A systematic review and meta-analysis on the use of PDE-5 inhibitors alone or in combination with a-blockers for lower urinary tract symptoms due to benign prostatic hyperplasia. Gacci M, et al. Eur Urol 2012;61:994.

The efficacy and safety of combined therapy with a-blockers and anticholinergics for men with BPH. Filson CP, et al. J Urol 2013;190:

thursday school december 11, 2014 richard hoffman, md, mph

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