Benign Prostatic Hyperplasia

Objectives

• Upon Completion of this CME activity, the learner will be able to:

– Understanding the current medical management for BPH

BPH

• Definition: Proliferation of the fibrostromal and glandular tissue of the prostate

• Not mutually exclusive to LUTS or BOO

• Typically found in men over age 60 (50%)

• Age 85 (90%)

BPH

• Clinical Features: – Obstructive Sx = weak

stream, hesitancy, straining, post void dribbling, sensation of incomplete emptying

– Irritative Sx = frequency, nocturia (most common), urgency

Progression• BPH does not progress in all patients– In men with mild LUTS, 57% progress to worse LUTS in 4 yrs– 30% remain stable– 15% improve– Only 10% progress to needing surgical intervention

• The risk of BPH progression is higher in men with…– Larger prostate size– Higher PSA– Older age– More severe LUTS

BPH Complications

Detrussor dysfunctionUrinary retentionHematuriaUTIRenal failureBladder calculi

EvaluationNon-Invasive Evaluation– Medical History– AUASS– DRE– UA– PSA– Voiding Diary– PVR– Uroflow – Creatinine

Evaluation

Invasive Evaluation– Pressure Flow study– Cystoscopy– TRUS

Diagnosis• Severity of BPH symptoms do not correlate with prostate size

or the degree of bladder outlet obstruction– Men with small prostates can have severe symptoms, etc

• Keys to diagnosis are…– Determining if there is Bladder Outlet Obstruction– Low flow on uroflow– Elevated post-void residuals– Trabeculation of bladder on cystoscopy– Low flow rate and high detrusor pressure on urodynamics

• DRE and PSA level are not absolute

• Must rule out infection and cancer which can cause similar symptoms

Management• Conservative Measures– Avoid substances that can exacerbate symptoms• α-agonists – decongestants that contain

pseudoephedrine• Anticholinergics in some cases• Caffeine / alcohol / spicy or acidic foods

–Reducing nocturia• Decreasing nightly fluid intake• Avoiding diuretics in evening• Elevating legs before bedtime for those with LE

edema

Management

• Medications– α-Blockers– 5α-Reductase Inhibitors– Combination Therapy

• Mostly commonly will progress to surgery if…– Patients are tired of taking medications– Symptoms present despite medications

Medications

• α-Blockers

– Terazosin (Hytrin)– Doxazosin (Cardura)

– Flomax– Rapaflow (most RGE)

– Uroxatral (least RGE) α-1 selective

Nonselective Nonselective α-blockersblockersDose dependent responseDose dependent response

αα-1A and D selective-1A and D selective

Medications• α-Blockers– Hytrin, Cardura, Flomax, Uroxatral, Rapaflow

• They relax the smooth muscle of the prostate stroma• Maximal response is usually 1-2 weeks• Side effects include:

– Dizziness, fatigue, nasal congestion, syncope, orthostatic hypotension, retrograde ejaculation, intraoperative floppy iris syndrome w/ cataract surgery

• Hytrin / Cardura may also be used to treat HTN

• Must also counsel pts on possibility of hypotension when combining PDE-5 inhibitors with nitrates or α-blockers.

Intraoperative Floppy Iris Syndrome (IFIS)

Recommendation: Men with LUTS secondary to BPH for whom alpha blocker therapy is offered should be asked about planned cataract surgery– Men planning surgery should avoid them until

cataract surgery is completed In men with no planned cataract surgery, there

are insufficient data to recommend withholding or discontinuing alpha blockers

Medications

• 5α-Reductase Inhibitors– Finasteride (Proscar) Type II Inhibitor– Dutasteride (Avodart) Type I & II Inhibitor

• They prevent conversion of testosterone to DHT• Reduce serum DHT levels by 70-90% and prostatic

DHT levels by 80-95%

• THEY TAKE SIX MONTHS TO WORK!!

Medications• 5α-Reductase Inhibitors– Proscar, Avodart

• They lower DHT and promote…– Reduces prostate volume by 20-25%– Increases maximum flow rate by 10%– Improves urinary symptom score by 20-30%– Reduces risk of urinary retention by 50%– Reduces need for surgical therapy by 50%– Reduces the risk of BPH progression by 34%– Reduces PSA by 50% after 6 months (no decrease think cancer)

• If on these meds, need to double PSA when looking at CaP screening

– May help stop chronic hematuria from prostate– Can be used for bleeding prevention in TURP

Medications

• Combination Therapy– Medical Therapy of Prostate Symptoms (MTOPS) Trial (McConnell,

et al, N Engl J Med, 2003)– 3047 men Age > 50 yrs Mean F/U 4.5 yrs– Cardura vs. Proscar vs. Both

BPH BPH ProgressionProgression

Urinary Urinary RetentionRetention

Need for Need for SurgerySurgery

CarduraCardura 39%39% No ChangeNo Change No ChangeNo Change

ProscarProscar 34%34% 68%68% 64%64%

CombinationCombination 66%66% 81%81% 67%67%

– Greatest benefit in men w/ PSA > 4.0 & Prostate Volume > 40 ccGreatest benefit in men w/ PSA > 4.0 & Prostate Volume > 40 cc– Greatest benefit in men w/ PSA > 4.0 & Prostate Volume > 40 ccGreatest benefit in men w/ PSA > 4.0 & Prostate Volume > 40 cc

Medications

CombAT trial– Compared tamsulosin, dutasteride and

combination– Combination showed better flow, AUASS and

reduced progression compared to tamsulosin alone

Medications

• Complimentary Therapies– AUA does not recommend these as standard

therapy• Mechanism of action is unknown or if they

change PSA– Sal palmetto is most widely used– Others include: African plum tree, Pumpkin seed,

African star grass, Rye pollen, Stinging nettle

Management• Surgical Options:

• Minimally Invasive Surgical Therapy (MIST)– TUNA, TUMT, or HIFU– Not currently offered at NMCP

• TUIP, TURP, and Open Simple Prostatectomy

• TURP vs. Vaporization– Traditional resection with a cutting loop– Photovaporization of the Prostate– Plasma button vaporization of the prostate– Holmium laser enucleation of the prostate

Questions?Questions?