when you gotta go, but can’t: management of benign...

When You Gotta Go, but Can’t: Management of

Benign Prostatic Hypertrophy (BPH) Florida A & M University

College of Pharmacy and Pharmaceutical Sciences42nd Annual Clinical Symposium

Wayne A. Sampson, M.D. Cross Creek Medical

Tallahassee, FL

Learning Objectives:

• Discuss the prevalence of prostate disorders and the general concerns of patients regarding their prostate health• Identify common symptoms associated with BPH• List the advantages and disadvantages of varied treatment

options for BPH and how to counsel patients with BPH with regard to treatment options• Review ways that management of prostate health

and counseling can fit into a Pharmacist's practice.

Prostate Anatomy

•Transition Zone • BPH Develops

•Peripheral Zone •Central Zone•Anterior Zone

Benign Prostatic Hypertrophy (BPH) Definition:

•BPH reflects the proliferation of epithelial and smooth muscle cells within the transition zone of the prostate.

•The term has been used to describe a constellation of voiding symptoms that occurs in men with aging.

Benign Prostatic Hypertrophy (BPH) Symptoms:

•Obstructive in nature as the hyperplastic tissue leads to a narrowing of the prostatic urethra•Decreased force of stream, hesitancy, straining, incomplete bladder emptying & nocturia


• Irritative symptoms include: urinary frequency, urgency & occasional dysuria •Lower Urinary Tract Symptoms (LUTS): preferred term to describe the complex of obstructive & irritative urinary symptoms that occur in both sexes.


•Voiding dysfunction in the aging male may be due to a variety of factors including changes in bladder, prostate and urethra but in many men, these symptoms are due to BPH•BPH is one of the most frequent diagnosis leading to a urology referral

Benign Prostatic Hypertrophy (BPH) Prevalence:

• It begins to develop before age 30 with –• 10% of men having histological evidence of BPH by age 40• 50% of men by age 60• 80% of men will develop BPH• 30% will receive treatment for BPH

• Significantly impacts patient’s quality of life• Substantial burden on the healthcare system

Benign Prostatic Hypertrophy (BPH) Diagnosis:

Objective Parameters: • Delineation of prostate size,

measurement of urinary flow rate and delineation of post-void residual volume

Subjective Parameters:• Several instruments are

available to quantify the severity of LUTS, but most clinicians use the American Urological Association Symptom Scale Index (AUASA) also known as the International Prostatic Symptom Score (IPSS)

Benign Prostatic Hypertrophy (BPH) Diagnosis: IPPS 0 – 35

•Mild Symptoms: • 0 – 7 Score

•Moderate Symptoms: • 7 -15 Score

• Severe Symptoms: > 15

Symptoms severity relates to urinary frequency, nocturia, weak urinary stream, hesitancy, incomplete bladder emptying and urinary urgency is assessed as well as effects on quality of life

Benign Prostatic Hypertrophy (BPH) Treatment:

•Drug Therapy: Medical therapy attempts to shrink or stop the growth of the prostate or open the urethral closure within the prostate without use of surgery


5-Alpha Reductase Inhibitors (5-ARIs)

• Decrease production of the hormone dihydrotestosterone (DHT) which is responsible for growth of the acinar glands of the prostate

• Finasteride • Dutasteride • Either prevents progression

of growth or actually shrink the prostate in some men


Alpha 1 – Adrenergic Receptor Blocker

• Relax the smooth muscle of the prostate and bladder neck to improve urine flow & reduce bladder outlet obstruction

• Terazosin*• Doxazosin*• Tamsulosin • Alfuzosin *developed as blood pressure agents


•Clinical data shows combination therapy reduces risk of BPH progression by 67% compared to 30% for Doxazosin alone and 34% for Finasteride alone

Benign Prostatic Hypertrophy (BPH) Conventional Surgical Therapy:

• Transurethral Resection of the Prostate TURP/TUIP –• 90% of all prostate surgeries for BPH

• Surgical “open” prostatectomy• Transurethral laser surgery

Benign Prostatic Hypertrophy (BPH) Minimally Invasive Therapies:

•Transurethral microwave procedure•Transurethral needle ablation•Water-induced thermotherapy•High intensity focus ultrasound

Benign Prostatic Hyperplasia and Prostate Specific Antigen (PSA)

• Produced by benign & malignant prostate• PSA is the enzyme responsible for liquefaction of the seminal fluid after ejaculation • PSA may also be transitory elevated in cases of prosthetic inflammation (prostatitis) or infection and after prostatic manipulation by biopsy • Routine DRE usually has little effect on serum PSA

Summary

• The prostate comprises of several regions and zones – 2 zones of interest are the peripheral zone where most cases of cancer arise and the transitional zone where BPH arise• The diagnosis of voiding dysfunction due to BPH is made based on both subjective and objective findings on clinical evaluation

Summary

• Medical treatment of BPH involves the use of agents that relaxes muscular stromal tissue of the bladder neck and prostatic urethra and reduction in the acinar glandular volume of the prostate through reduced DHT production • Indications for surgical intervention for BPH includes urinary retention, gross hematuria, bladder stones and urinary tract infection

Summary

•Serum PSA increases over time with both BPH and prostate cancer which makes it a difficult diagnostic marker for cancer alone

References

1. Beckman TJ, Mynderse LA. Evaluation and medical management of benign prostatic hyperplasia. Mayo Clin Proc. 2005;80(10):1356-1362.

2. McVary KT. BPH: epidemiology and comorbidities. Am J Manag Care. 2006;12(5 Suppl):S122-S128.3. Deters LA. Benign Prostatic Hypertrophy Treatment and Management. Available at http://emedicine.medscape.com/article/437359-treatment. Last accessed June 15, 2016.4. Barry MJ, Fowler FJ Jr, O'Leary MP, et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. 5. Wei JT, Calhoun E, Jacobsen SJ. Urologic Diseases in America Project: benign prostatic hyperplasia. J Urol. 2005;173(4):1256-1261.6. Miller MS. Role of phosphodiesterase type 5 inhibitors for lower urinary tract symptoms. Ann Pharmacother. 2013;47(2):278-283.Cantrell MA, Baye J, Vouri SM. Tadalafil: a phosphodiesterase-5 inhibitor for benign prostatic hyperplasia. Pharmacotherapy. 2013;33(6):639-649.7. Hoke GP, McWilliams GW. Epidemiology of benign prostatic hyperplasia and comorbidities in racial and ethnic minority populations. Am J Med. 2008;121(8 Suppl 2):S3-S10.8. Kramer BS, Hagerty KL, Justman S, et al. Use of 5-α-reductase inhibitors for prostate cancer chemoprevention: American Society of Clinical Oncology/American Urological Association 2008 Clinical Practice Guideline. 9. Wilt TJ, MacDonald R, Hagerty K, Schellhammer P, Kramer BS. Five-alpha-reductase inhibitors for prostate cancer prevention. Cochrane Database Syst Rev. 2008;(2):CD007091.10. Roehrborn CG, Barkin J, Siami P, et al. Clinical outcomes after combined therapy with dutasteride plus tamsulosin or either monotherapy in men with benign prostatic hyperplasia (BPH) by baseline characteristics: 411. Marks LS, Gittelman MC, Hill LA, et al. Rapid efficacy of the highly selective α(1A)-adrenoceptor antagonist silodosin in men with signs and symptoms of benign prostatic hyperplasia: pooled results of 2 phase 3 studies.

http://emedicine.medscape.com/article/437359-treatment

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