BENIGN PROSTATIC HYPERPLASIA

GENERAL DATA

This is the case of F.G., 56 year old male, married, Filipino, Catholic, currently residing in San Antonio, Binan, Laguna. Admitted for the first time in this institution last January 5, 2011.

Chief Complaint

“ Hirap at meron dugo sa ihi.”

( Difficulty in voiding and Presence of Blood in the

Urine)

History of Present Illness

One week prior to admission he experienced pain during urination and found a tinge of blood in his urine.

January 5,2011 : Patient continued to have the said symptom and at around 10PM was admitted to this institution.

Physical Examination

Gen. Survey Conscious, coherent (-) cyanosis

Vital Signs BP- 110/70 mmHg RR-21 bpm PR-80 bpm Temp-36.7

Skin Dry skin, decreased skin turgor, pale

HEENT Pink palpebral conjuctiva, anisteric sclera

Chest and Lungs Symmetrical chest expansion

Heart Adynamic Precordium

Abdomen Non tender abdomen, NABS

Extremities (+) Edema on both Upper and Lower Extremeties

Laboratory Exams

Complete Blood CountResults:

Hct- 20.3 % Platelet- 22.6 WBC- 24.4 g/l (Elevated; NV= 4.3-10 g/l ) Granulocytes- 3 Lympho/Mono- 17 Hgb- 67 ** Elevated WBC is indicative of infection

Fasting Blood Sugar – Normal Result: 107 mg/dL ( NV= < 126 mg/dl )

BUN - Normal Result : 17.4 mg/dL (NV= 7-21 mg/dL)

Serum Creatinine - Normal Result: 1.0 mg/dL (NV= 0.60- 1.7 mg/dL)

Urinalysis - Normal Color- yellow Specific Gravity- 0.010  pH- 7.5 Appearance- turbid Pus cells- 1-3 hpf  Red cells- 15-25 hpf

Fecalysis - Normal Color- dark brown Consistency- soft

Family History

(-) HPN (-) DM (-) Asthma

Past Medical History

2008 – Benign Prostatic Hyperplasia (-) Previous Hospitalizations

Personal and Social History

(+) Occasional alcoholic beverage drinker

(-) Smoking (-) Allergy to food and drugs

Review of Systems

Unremarkable

Diagnosis

Benign Prostatic Hyperplasia

Differential Diagnosis

Urethritis Urolithiasis Bladder Neck Contracture

Discussion

Pathophysiology

BPH is the most common benign tumor in males

Characterized by hyperplasia of prostatic stromal and epithelial cells, resulting in the formation of large, fairly discrete nodules in the periurethral region (transition zone) of the prostate

It is believed that the main component of the “hyperplastic” process is impaired cell death

Overall reduction of the rate of cell death, resulting in the accumulation of senescent cells in the prostate

The main androgen in the prostate, constituting 90% of total prostatic androgens, is dihydrotestosterone (DHT)

Dihydrotestosterone (DHT)

Formed in the prostate from the conversion of testosterone by the enzyme type 2 5α-reductase

Located almost entirely in stromal cells epithelial cells of the prostate do not

contain type 2 5α reductase, with the exception of a few basal cells

stromal cells are responsible for androgen-dependent prostatic growth

DHT is more potent androgen than testosterone higher affinity for androgen receptor

(AR) Binding of DHT to AR activates the

transcription of androgen-dependent genes

DHT is not a direct mitogen for prostate cells DHT-mediated transcription of genes

results in the increased production of several growth factors and their receptors

fibroblast growth factor (FGF) family, and particularly FGF-7 (keratinocyte growth factor)

FGF-7, produced by stromal cells, is probably the most important factor mediating the paracrine regulation of androgen-stimulated prostatic growth. Other growth factors produced in BPH are FGFs 1 and 2, and TGFβ, which promote fibroblast proliferation.

Clinical Findings

Obstructive Symptoms Hesitancy Decreased force and caliber of stream Sensation of incomplete bladder

emptying Double voiding Straining to urinate Postvoid dribling

Irritative Symptoms▪ secondary response of the bladder to the

increased outlet resistance Urgency Frequency Nocturia

Diagnostic Tests

Digital Rectal Exam Smooth, firm, elastic enlargement of the

prostate Urinalysis Serum Creatinine Postvoid Residual Urine Ultrasound Urethrocystoscopy

Treatment

American Urological Association Symptom Index for BPH

mild (0 to 7), moderate (8 to 19), or severe (20 to 35)

Management

Watchful Waiting Medical Therapy

α- Blockers 5α- Reductase Inhibitors Combination Therapy Phytotherapy

Conventional Surgical Therapy Transurethral resection of the Prostate ( TURP) Transurethral Incision of the Prostate Open Simple Prostatectomy

Minimally Invasive Therapy Laser Therapy (TULIP) Transurethral Needle Ablation of the Prostate

(TUNA) Transurethral Electrovaporization of the

Prostate

ESSA CRITERIA

DRUGE

(Effectivity)

S(Safety)

S(Suitabili

ty)

A(Affordabilit

y)Total

Finasteride

++++ +++ ++++ ++++(P 44.40)

15

Tamsulosin

+++ +++ +++ ++(P 88.00)

11

Terazosin ++ + ++ +(P 153.50)

6

Doxazosin ++ ++ + +++(P 69.00)

8

Pharmacologic AgentFinasteride (5α- Reductase Inhibitor)

Finasteride

Finasteride

Steroid like 5-alpha reductase inhibitor which interfere with the effect of certain male hormones (androgens) on the prostate.

Blocks the conversion of testosterone to DHT

Causes reduction in DHT levels that begins within 8 hours after administration and lasts for about 24 hours.

Absorption: Absorbed from the GI tract (oral); peak plasma concentrations after 1-2 hr.

Distribution: Protein-binding: 90%.Metabolism: Hepatic.Excretion: Urine and feces (as

metabolites); <60 yr: 6 hr; >70 yr: 8 hr (elimination half-life)

Effect of Finasteride in decreasing the size of the prostate can be seen only if patient continues to take the medication for at least 6 months.

Contraindications

Hypersensitivity to one of its components

Pregnancy Hypertension

If patient is hypertensive it is best to useα- Blockers ( Tamzolasin, Alfazosin )

Special Precautions

Undiagnosed Prostate Cancer Finasteride lowers Serum PSA levels

masking the diagnosis of Prostate CA Liver Dysfunction

It is extensively metabolized in the liver Obstructive Uropathy

Adverse Effects

Impotence - (1.1 -18.5%) Abnormal Ejaculation – (7.2%) Decreased Ejaculatory Volume –

( 0.9-2.8%) Abnormal Sexual Function – ( 2.5%) Gynecomastia – (2.2%) Erectile Dysfunction – ( 1.3%) Ejaculatory Disorder – (1.2%) Testicular Pain

P

PAUL ANDREW M. GOROSPE, MDINTERNAL MEDICINE- UROLOGIST

ASIAN HOSPITAL, MUNTINLUPA CITYRM. 1025 TTHS 8:00-10:00 AM

Name: Myk Pizzaro Date: 10/14/2011Address: Molino, Cavite Age/Sex: 50/M

RX: FINASTERIDE 5mg/tab #30 ( Atepros )

Sig: take 1 tab everyday for 1 monthRefill: NoneFollow-Up: to be seen on 11/10/2011

Paul Andrew M. Gorospe, MD Lic. Number: 123456 PTR Number: 123456

P

THANK YOU