Transcript BPH FAHC resident clinic

All About the Prostate
For Intelligent Internists
Part 1: Benign Prostatic
Hyperplasia
Objectives
Part A: Diagnosis
Formulate a differential diagnosis for LUTS
Perform appropriate evaluation/ w/u
Use the AUA symptom score to assess
severity
Part B: Management
 counsel on what to expect from
medications
 appropriately manage persistent
symptoms
Diagnosis: MKSAP!
• An 80-year-old man is evaluated for a 1-year history of progressive
urinary symptoms including weak stream, hesitancy, and nocturia
four times nightly. He has coronary artery disease and chronic heart
failure. His current medications are lisinopril, isosorbide dinitrate,
aspirin, and metoprolol.
• On physical examination, vital signs are normal. He has mild
suprapubic tenderness and a symmetrically enlarged prostate
without nodules or tenderness. The remainder of the physical
examination is normal.
• Which of the following is the most appropriate diagnostic test to
perform next?
A. Postvoid residual urinary volume measurement
B. Plasma glucose level
C. Prostate-specific antigen testing
D. Transrectal ultrasound
E. Urinalysis
Anatomy of a large prostate
• Prevalence: 25% of men in 40s, 80% in 70s
• not all are symptomatic
LUTS!
More than half of men in their 60s have LUTS
• LUTS ≠ BPH
• Storage, Voiding, Postmicturition Sx
Differential Diagnosis
• bladder irritants (e.g. caffeine, alcohol) or excess
fluid
• Diuretics, anticholinergic, antihistaminic meds
• UTI/prostatitis
• Overactive Bladder
• Neurogenic Bladder (e.g. parkinson’s, spinal cord)
• Bladder, prostate Ca
Workup
• U/a generally indicated
• (eval for UTI/hematuria)
• *Consider* DRE/PSA to evaluate for
prostate ca after discussing risks/harms
• Might also consider DRE to evaluate
prostate size as it pertains to management
• PVR if sensation of incomplete emptying
(or renal insufficiency and suspect
postrenal issue)
Diagnosis: MKSAP!
• An 80-year-old man is evaluated for a 1-year history of progressive
urinary symptoms including weak stream, hesitancy, and nocturia
four times nightly. He has coronary artery disease and chronic heart
failure. His current medications are lisinopril, isosorbide dinitrate,
aspirin, and metoprolol.
• On physical examination, vital signs are normal. He has mild
suprapubic tenderness and a symmetrically enlarged prostate
without nodules or tenderness. The remainder of the physical
examination is normal.
• Which of the following is the most appropriate diagnostic test to
perform next?
A. Postvoid residual urinary volume measurement
B. Plasma glucose level
C. Prostate-specific antigen testing
D. Transrectal ultrasound
E. Urinalysis
AUA Symptom Score/I-PSS
• Part of initial evaluation that can help
confirm dx and guide management
• 35 point scale
• In prism: .aua
• Used to evaluate response to therapy
• 3-4 point difference clinically
significant
Objectives
Part A: Diagnosis
Formulate a differential diagnosis for LUTS
Perform appropriate evaluation/ w/u
Use the AUA symptom score to assess
severity
Part B: Management
 counsel on what to expect from
medications
 appropriately manage persistent
symptoms
Management: MKSAP!
• A 68-year-old man is evaluated for continuing urinary frequency and
nocturia. His symptoms have been slowly progressive over the past 1 to 2
years with a weak urinary stream and hesitancy. He was started on
doxazosin 6 months ago, which he tolerates well and initially provided some
improvement. However, his symptoms have continued and are beginning to
interfere with his quality of life, particularly the urinary frequency and
nocturia. His only other medical problem is hypertension, for which he takes
lisinopril and metoprolol.
• On physical examination, he is afebrile, blood pressure is 140/85 mm Hg,
pulse rate is 70/min, and respiration rate is 14/min. BMI is 25. He has a
symmetric moderately enlarged prostate gland with no prostate nodules or
areas of tenderness. A urinalysis is normal.
• Which of the following is most appropriate next step in treatment of this
patient's benign prostatic hyperplasia?
A. Add finasteride
B. Change doxazosin to finasteride
C. Change doxazosin to tamsulosin
D. Prescribe a fluoroquinolone antibiotic for 4 weeks
Management
• AUA < 8 -> watchful waiting usually appropriate
• AUA >8 usually med mgmt
• Keep it patient centered! depends on how
bothersome sx are.
• Absolute indications for treatment?
•
•
•
•
Postrenal AKI
Urinary retention (PVR >250? 300?)
Bladder stones
Recurrent UTIs
Alpha-1 blockers
• All equally effective in head to head studies
• More efficacious than finasteride for reducing
symptoms
• Selective have a better safety profile, but more $
5-α reductase inhibitors
Finasteride/Dutasteride
• Decreases size of prostate (part of inclusion criteria for
studies: prostates>30 g on US, PSA >1.5)
• 5-year trial shown to decrease risk of urinary retention and
surgery
• Takes ~6 months for improvement in AUA score
Side Effects
• Decreased libido, ED, gynecomastia
• Will decrease PSA by ~50% at 6 months
• May reduce incidence of prostate cancer overall but
increase risk of high grade prostate ca
Combination therapy
• One-year trial 1996 showed combination
therapy not superior to terazosin alone in
reducing symptom scores and urinary flow rates
• MTOPS trial 2003:
• mean f/u 4.5 years
• AUA score 8-30
• Composite Primary Outcome: Clinical progression
• increase in AUA score ≥4, acute urinary retention,
renal insufficiency, incontinence, recurrent UTI
• Secondary outcomes: improvement in AUA score
MTOPS Take-Homes
Significant reduction in composite clinical progression
with combination than either doxazosin or finasteride alone
 not better than alpha blocker alone in preventing
progression of AUA scores (although AUA more
improved by year 5 with combo vs. doxazosin alone:
7 points vs. -6)
not better than finasteride alone in risk of urinary
retention/invasive therapy
 more AEs, more $
Who might you choose combo tx for?
failure of alpha blocker tx alone
large prostate size/higher PSA?
higher AUA score? Urinary retention?
-
Other options
• Antimuscarinics (oxybutynin)
• If predominantly storage sx (frequency, urgency)
• In men with PVR <250, reduced symptoms when
added to α –blocker, did not increase risk of retention
• PDE inhibitors (tadalafil 5 mg daily)
• PDE present in prostatic tissue: PDE-I may enhance
smooth muscle relaxation, decrease proliferation of
hyperplasia
• Reduced AUA score 3.8 points at 12 weeks
• Saw Palmetto? Data does not show efficacy
When to Refer to Urology
• Refractory sx
• Urinary retention
• recurrent UTIs
• Rising PSA if you choose to monitor (e.g. on 5alpha reductase inhibitor)
Management: MKSAP!
• A 68-year-old man is evaluated for continuing urinary frequency and
nocturia. His symptoms have been slowly progressive over the past 1 to 2
years with a weak urinary stream and hesitancy. He was started on
doxazosin 6 months ago, which he tolerates well and initially provided some
improvement. However, his symptoms have continued and are beginning to
interfere with his quality of life, particularly the urinary frequency and
nocturia. His only other medical problem is hypertension, for which he takes
lisinopril and metoprolol.
• On physical examination, he is afebrile, blood pressure is 140/85 mm Hg,
pulse rate is 70/min, and respiration rate is 14/min. BMI is 25. He has a
symmetric moderately enlarged prostate gland with no prostate nodules or
areas of tenderness. A urinalysis is normal.
• Which of the following is most appropriate next step in treatment of this
patient's benign prostatic hyperplasia?
A. Add finasteride
B. Change doxazosin to finasteride
C. Change doxazosin to tamsulosin
D. Prescribe a fluoroquinolone antibiotic for 4 weeks