Transcript 슬라이드 1
BPH Diagnosis and Medical Treatment BPH The most common disease of aging men Present in majority of men Prevalence : 60yr : 50%↑ 85yr : 90% Wide variance in symptoms Large prostate does not equal voiding problems LUTS Morbidity & Complication of BPH Mortality of BPH : Rare LUTS : Bothersome Highly variable Treatment : Patient’s perception Degree of interfering life style Definitions and Terminology BPH : Stromal and epithelial hyperplasia in periuretheral zone LUTS : Lower urinary tract symptoms The relationship of BPH & LUTS : Complex LUTS or LUTS suggestive of BPH >> prostatism BPH : Bothersome LUTS by histological BPH or increased tone of the prostate LUTS Irritative versus Obstructive Irritative Obstructed Frequency/urgency/nocturia Slow stream/stranguria/start-stop Difficult to distinguish by history alone since symptoms overlap Initial Evaluation History DRE & Focused PE UA PSA in select patients AUA/IPSS Sx Index, Bother Medical History Surgery, general health Voiding History: polyuria, stranguria, frequency, urgency post void dribbling Voiding diary (nocturia) Urinary Infections :culture Incontinence Physical Examination DRE Neurologic exam Mental status Ambulatory status Neuromuscular function Anal sphincter tone Urinalysis Bladder cancer, CIS UTI, Urethral stricture Urethral, bladder stones PSA Screening for cancer 10 year life expectancy and for whom the presence of cancer would change management One predictor of natural Hx of BPH Optional Initial Test Urine Cytology : Bladder Ca, CIS Predominantly irritative Sx Smoking or other risk factors Serum Creatinine : Not recommended Renal insufficiency : 1%↓ Not more common than general population Non BPH cause as diabetic nephropathy Symptom Assessment Sx alter QOL Sx quantification Severity of disease Response of therapy Sx progression 0~7 : mild 8~19 : moderate 20~35 : severe Not a replacement for personal discussion of Sx with the patient Symptom Assessment IPSS : Recommended Other validated assessment : optional Frequency and severity of LUTS Bother score Interference with daily activities Urinary incontinence Sexual function Health related – QOL ICS Questionnaire, DPSS, BPH impact index, IPSS QOL, Sexual function Questionnaire QOL Optional Diagnostic Test Uroflometry measures rate of urine flow Not a first line test Post-void residual urine (PVR) useful tool for evaluation and treatment Non-prostatic case of Sx Selection of invasive Tx Prior failed BPH Tx Quantitative method to diagnose and follow result of treatment Qmax : rate of urine flow Predict the response to surgery Predict the natural Hx of BPH Advantages LUTS with Normal Qmax : non prostatic cause Qmax < 10ml/sec : obstruction Disadvantages Sx response is not dependent on Qmax Test / retest variability, lack of well designed study → Not feasible to establish cut-point PVR Bladder dysfunction Identifies favorable response to Treatment Progression of disease Clinical tool not a singular diagnostic test Test / retest variability Lack of outcome studies No PVR cut-point Optional Doesn’t predict the response to medical Tx Elevated PVR without UTI, renal insufficiency, bothersome Sx - No level of RU mandates invasive Tx Optional Diagnostic Tests Who Choose Invasive Tx Pr-flow study Qmax > 10ml/sec & surgery considered Prior failed surgery Neurologic disease Not indicated to predict response to medical Tx Cystoscopy : Hematuria, urethral stricture r/o Bladder Ca, prior surgery TRUS : Size & shape, selection of surgery CMG, IVP, USG of Kidney Not recommended Indicated in Hematuria, UTI Renal insufficiency, stone Hx, upper tract surgery Hx Initial Management and Discussion of Treatment Options Watchful waiting Medical therapy – pills Minimally invasive surgery Surgery Treatment Watchful waiting Mild Symptoms Mod or severe Symptoms without Renal insufficiency, UTI, retention Increase water intake↓ Decrease alcohol↓, Caffeine↓ SODA DRE, PSA : suggests natural Hx of Sx flow rate, AUR, surgery Medical Treatment Options 1. 2. 3. 4. Alpha-adrenergic blockers 5 alpha-reductase inhibitors Combination therapies Phytotherapy Alpha-adrenergic Blockers Opens prostatic urethra by relaxing smooth muscle in prostate Doxazosin, terazosin, flomax, uroxatrol and rapaflo Equal effectiveness Differences in adverse events LUTS secondary to BPH Very effective in relieving symptoms of BPH Alpha-adrenergic Blockers Side Effects: postural hypotension, retrograde ejaculation Hypertension and cardiac risk factors LUTS – Alpha blocker only: incidence of CHF Patients with hypertension : separate management of hypertension May make cataract surgery difficult (floppy iris syndrome) 5 Alpha-reductase Inhibitors Reduces prostate volume 25-28% Reducing volume doesn’t always relieve obstruction Symptomatic prostatic enlargement treatment helps to prevent progression of disease (AUR, surgery) Sexual dysfunction, long-term Tx Not appropriate for men with LUTS without prostatic enlargement Natural History of BPH PLESS study 1. 3,040 clinical BPH patients 2. IPSS: moderate to severe 3. Qmax: <15 ml/s 4. DRE: enlarged prostate gland 5. PSA <10 ng/ml (PSA 4-9.9: negative biopsy) 6. Follow-up: 4 years Natural History of BPH Risk of Acute Urinary Retention or Surgery Natural History of BPH Change of Symptom Score Natural History of BPH Change of Peak Urinary Flow Rate Surgery Minimally Invasive (office) Microwave TUNA Interstitial Laser Surgery (operating room) TURP HOLAP HOLEP Surgery Patient selection determines type of procedure offered Surgery very effective in properly selected patients Majority of patients stop medications Absolute indications Retention Recurrent infections Bleeding Stones Surgery Absolute Indications Retention Repeated infection Bladder stones Relative indications Worsening symptoms Rising urine retention Desire to stop medication Surgery Minimally invasive surgery Better symptom results than medication Minimal recovery – days Low incidence of long-term side effects No incontinence after treatment Higher future retreatment rates than surgery Not effective for patients in urine retention Excellent alternative to medication Surgery OR based surgery Most effective means of relieving prostate obstruction Requires general/spinal anesthesia Removal of prostate tissue Variety of energies used to remove tissue Requires catheters after treatment Usually involves hospitalization Surgery Indicated for urine retention Highest side effects Possible incontinence Retrograde ejaculation Best treatment outcomes Improves flow rate Lowers voiding symptoms Recommendations Goal directed therapy Most patients have a variety of treatment options Medical management works well for most patients with minimal side effects Modern procedures are effective and safe Informed patient decision making : benefits, risks, costs