BENIGN PROSTATIC HYPERPLASIA Module 2 of RenalProstate Disease

BENIGN PROSTATIC HYPERPLASIA (Module 2 of Renal/Prostate Disease) Bill Lyons, M. D. UNMC Geriatrics & Gerontology

BPH: LEARNING OBJECTIVES n Pathophysiology and n n Epidemiology Workup Differential Diagnosis Medical Treatment Surgical Treatment

BACKGROUND n Incidence age-related n Autopsy studies, BPH prevalence: n 20% men in their 40 s n 90% men over 80 n Two ingredients for BPH n Androgens (dihydrotestosterone): castration shrinks established BPH, improves symptoms n Aging (aging prostate more androgensensitive)

BACKGROUND, cont. n Prostate: stromal +epithelial tissues n BPH from either alone or in combination n Stroma has abundant adrenergic innervation n Increased tone increased resistance to urine flow through prostatic urethra

BPH: PATIENT HISTORY n Symptoms: Obstructive & Irritative n Obstructive n Increased resistance to flow n Neck of bladder, prostatic urethra n Static and dynamic components n Irritative n From bladder’s response to flow resistance n Hypertrophy + collagen deposition n Detrusor instability, less passive compliance

OBSTRUCTIVE VOIDING SYMPTOMS n Hesitancy n Reduced force of stream n Sense of incomplete emptying n Intermittent flow n Strain to urinate n Post-void dribbling

IRRITATIVE VOIDING SYMPTOMS n Urgency n Frequency n Nocturia

AUA QUESTIONNAIRE n Seven questions, each 0 -5, total 0 -35 n Evaluate before start therapy, and to assess results n n n n of therapy. Over the last month: 1 Incomplete Emptying? 2 Frequency – go again less than 2 hr later? 3 Intermittency stop/start several times? 4 Urgency – difficult to postpone urinating? 5 Weak Stream? 6 Straining – push/strain to begin? 7 Nocturia – how many times on typical night?

DIFFERENTIAL DIAGNOSIS n Prostate cancer n Bladder stone n UTI (also BPH complication) n Urethral stricture (trauma, instrumentation, urethritis) n Contracture of bladder neck (instrumentation) n Neurogenic bladder (CVA, MS, trauma, DM)

PHYSICAL EXAMINATION n DRE – size, consistency, tenderness n Size of gland correlates poorly with symptoms

PHYSICAL EXAM, cont. n Abdomen – palpation, percussion n Enlarged bladder? n Normal = well below umbilicus n Neurological n Perineal sensation n Sphincter tone n Anal wink n Bulbocavernosus reflex

ADDITIONAL STUDIES n Urinalysis and urine culture n Serum creatinine n PSA controversial (BPH, cancer overlap) n Upper tract imaging for hematuria, renal insufficiency n Post-void residual n Urodynamic studies Suspected neurologic disease n Failed surgery n

MEDICAL TREATMENT n Alpha blockers perhaps better if significant component of stromal smooth muscle n 5 -alpha-reductase inhibitors for BPH from primarily excess epithelial tissue

MEDICAL TREATMENT, cont. n Cannot predict response to a particular therapy

MEDICAL TREATMENT, cont. n Mild BPH: watchful waiting n Prostate and bladder neck contraction mediated via alpha-1 a receptors n Alpha Blockers: Alpha-1: prazosin, terazosin, doxazosin n Alpha-1 a: tamsulosin n

MEDICAL TREATMENT, cont. n Alpha Blockers, cont. n Dosed daily: terazosin, doxazosin, tamsulosin n Dosed bid: prazosin n Slow dose escalation required (perhaps less so with tamsulosin) n Side Effects: orthostatic hypotension and dizziness, headache, rhinitis and nasal congestion, retrograde ejaculation, fatigue

MEDICAL TREATMENT, cont. n 5 -alpha-reductase inhibitor: finasteride n Blocks conversion of testosterone DHT n Reduces epithelial component of prostate, shrinks gland, decreases PSA n Months (>6) of treatment before improvement n Symptoms better only if large prostate? n Side Effects: reduced libido, erectile dysfunction

MEDICAL TREATMENT, cont. n Combine alpha blockade and finasteride? n RCT over 3000 men (Mc. Connell et al, NEJM 2003) Mean age 63, mean f/u 4. 5 years n Doxazosin vs. finasteride vs. combo vs. placebo n Clinical progression: combo > either drug > placebo n

MEDICAL TREATMENT, cont. n Combination Therapy, continued n Placebo-controlled Prostate Cancer Prevention Trial: n n n Finasteride reduced overall prevalence of prostate cancer But increased proportion of poorly-differentiated cases Experts debating whether true harm

MEDICAL TREATMENT, cont. n Consider adding finasteride n Men with large prostate n Progressing symptoms n Discuss risk

SURGERY n Who to refer for interventions?

SURGERY, cont. n Consider for referral: n Refractory retention n n Failed attempt at d/c of catheter Overflow incontinence Large bladder diverticula n Recurrent UTI n Recurrent/persistent gross hematuria n Bladder stones n Renal insufficiency n

SURGERY, cont. n Transurethral Resection of the Prostate n Spinal anesthesia n 1 -2 day hospital stay n Better symptom scores than minimallyinvasive methods n Risks: ED, incontinence, retrograde ejaculation, urethral stricture/bladder neck contracture n Urgency/frequency may persist

SURGERY, cont. n Transurethral Incision of the Prostate n Faster, less morbid than TURP n Requires right prostate anatomy (small gland) n Higher rate of reoperation vs. TURP n But less incidence of stricture, incontinence, retrograde ejaculation

SURGERY, cont. n Open Prostatectomy n When gland too large to treat otherwise n Bladder stones, diverticula n Minimally Invasive Procedures n Laser, needle ablation, electrovaporization, hyperthermia, ultrasound n Need RCT, long-term follow-up n Intraurethral stents n Patients with short life expectancy, high risk

REFERENCES AND READINGS n Lieber MM. Mayo Clin Proc 1998; 73: 590 -596. n Mc. Connell JD et al. NEJM 2003; 349: 2387 - 2398. n Stoller ML, Carroll PR. Urology. Chapter 23 in: Tierney LM Jr, Mc. Phee SJ, Papadakis MA, Current Medical Diagnosis & Treatment, 2004, Mc. Graw-Hill. n Thompson IM et al. NEJM 2003; 349: 215 -224.

Post-test 1 You assume the care of a 75 -year-old man who was recently discharged from the hospital, where he had undergone treatment for diverticulitis. In reviewing his hospital discharge summary, you find that an abdominal and pelvic CT was performed, showing sigmoid diverticulitis, a simple right renal cyst, a large urinary bladder diverticulum, and pronounced prostatomegaly. Clinically, his diverticulitis has resolved, but he complains of chronic nocturia, urinary frequency, sense of incomplete emptying, and straining to initiate his urinary stream. Symptoms are modestly improved on a regimen of terazosin 5 mg qhs and finasteride 5 mg qd. Other past medical history includes knee osteoarthritis, diet-controlled diabetes mellitus, recurrent urinary tract infections, and depression. The best approach to treating this man’s urinary complaints is to:

The best approach to treating this man’s urinary complaints is to: (a) Check his PSA, and consider referral for prostate biopsy, depending on the result. (b) Increase the dose of his terazosin. (c) Refer him to a urologist for consideration of TURP. (d) Refer him to a urologist for consideration of an open procedure. (e) Prescribe a bladder relaxant, such as oxybutynin.

Correct Answer: (d) Refer him to a urologist for consideration of an open procedure. Feedback: (d) This patient’s recurrent urinary tract infections and bladder diverticulum suggest that he is more appropriately managed by surgical intervention than by medications alone. The presence of the large diverticulum makes it likely that he will need an open procedure prostatectomy and diverticulectomy/bladder repair. Checking his PSA is not likely to be helpful, as a high PSA is nonspecific and may represent BPH, prostate cancer, or urinary tract infection. Increasing the dose of terazosin might be the right choice, if not for the recurrent UTIs and bladder diverticulum. TURP may help with the obstructive symptoms, but won’t solve the diverticulum problem. And prescribing a bladder relaxant would likely make matters worse by increasing the risk of urinary retention.