Transcript BENIGN PROSTATE HYPERPLASIA (Module 2 of Renal

BENIGN PROSTATIC
HYPERPLASIA (Module 2
of Renal/Prostate Disease)
Bill Lyons, M.D.
UNMC Geriatrics & Gerontology
BPH: LEARNING OBJECTIVES
 Pathophysiology and
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Epidemiology
Workup
Differential Diagnosis
Medical Treatment
Surgical Treatment
BACKGROUND
 Incidence age-related
 Autopsy studies, BPH prevalence:
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20% men in their 40s
90% men over 80
 Two ingredients for BPH
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Androgens (dihydrotestosterone): castration
shrinks established BPH, improves symptoms
Aging (aging prostate more androgensensitive)
BACKGROUND, cont.
 Prostate: stromal
+epithelial tissues
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BPH from either alone
or in combination
 Stroma has abundant
adrenergic innervation
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Increased tone 
increased resistance to
urine flow through
prostatic urethra
BPH: PATIENT HISTORY
 Symptoms: Obstructive & Irritative
 Obstructive
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Increased resistance to flow
Neck of bladder, prostatic urethra
Static and dynamic components
 Irritative
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From bladder’s response to flow resistance
Hypertrophy + collagen deposition
Detrusor instability, less passive compliance
OBSTRUCTIVE VOIDING
SYMPTOMS
 Hesitancy
 Reduced force of stream
 Sense of incomplete emptying
 Intermittent flow
 Strain to urinate
 Post-void dribbling
IRRITATIVE VOIDING SYMPTOMS
 Urgency
 Frequency
 Nocturia
AUA QUESTIONNAIRE
 Seven questions, each 0-5, total 0-35
 Evaluate before start therapy, and to assess results
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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
 Prostate cancer
 Bladder cancer
 Bladder stone
 UTI (also BPH complication)
 Urethral stricture (trauma, instrumentation,
urethritis)
 Contracture of bladder neck (instrumentation)
 Neurogenic bladder (CVA, MS, trauma, DM)
PHYSICAL EXAMINATION
 DRE – size,
consistency, tenderness
 Size of gland correlates
poorly with symptoms
PHYSICAL EXAM, cont.
 Abdomen – palpation, percussion
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Enlarged bladder?
Normal = well below umbilicus
 Neurological
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Perineal sensation
Sphincter tone
Anal wink
Bulbocavernosus reflex
ADDITIONAL STUDIES
 Urinalysis and urine culture
 Serum creatinine
 PSA controversial (BPH, cancer overlap)
 Upper tract imaging for hematuria, renal
insufficiency
 Post-void residual
 Urodynamic studies
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Suspected neurologic disease
Failed surgery
MEDICAL TREATMENT
 Alpha blockers perhaps better if significant
component of stromal smooth muscle
 5-alpha-reductase inhibitors for BPH from
primarily excess epithelial tissue
MEDICAL TREATMENT, cont.
 Cannot predict
response to a particular
therapy
MEDICAL TREATMENT, cont.
 Mild BPH: watchful waiting
 Prostate and bladder neck contraction
mediated via alpha-1a receptors
 Alpha Blockers:
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Alpha-1: prazosin, terazosin, doxazosin
Alpha-1a: tamsulosin
MEDICAL TREATMENT, cont.
 Alpha Blockers, cont.
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Dosed daily: terazosin, doxazosin, tamsulosin
Dosed bid: prazosin
Slow dose escalation required (perhaps less
so with tamsulosin)
Side Effects: orthostatic hypotension and
dizziness, headache, rhinitis and nasal
congestion, retrograde ejaculation, fatigue
MEDICAL TREATMENT, cont.
 5-alpha-reductase inhibitor: finasteride
 Blocks conversion of testosterone  DHT
 Reduces epithelial component of prostate,
shrinks gland, decreases PSA
 Months (>6) of treatment before improvement
 Symptoms better only if large prostate?
 Side Effects: reduced libido, erectile
dysfunction
MEDICAL TREATMENT, cont.
 Combine alpha blockade and finasteride?
 RCT over 3000 men (McConnell et al, NEJM
2003)
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Mean age 63, mean f/u 4.5 years
Doxazosin vs. finasteride vs. combo vs.
placebo
Clinical progression: combo > either drug >
placebo
MEDICAL TREATMENT, cont.
 Combination Therapy, continued
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Placebo-controlled Prostate Cancer
Prevention Trial:
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Finasteride reduced overall prevalence of
prostate cancer
But increased proportion of poorly-differentiated
cases
Experts debating whether true harm
MEDICAL TREATMENT, cont.
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Consider adding
finasteride
 Men with large
prostate
 Progressing
symptoms
 Discuss risk
SURGERY
 Who to refer for
interventions?
SURGERY, cont.
 Consider for referral:
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Refractory retention
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Failed attempt at d/c of catheter
Overflow incontinence
Large bladder diverticula
Recurrent UTI
Recurrent/persistent gross hematuria
Bladder stones
Renal insufficiency
SURGERY, cont.
 Transurethral Resection of the Prostate
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Spinal anesthesia
1-2 day hospital stay
Better symptom scores than minimallyinvasive methods
Risks: ED, incontinence, retrograde
ejaculation, urethral stricture/bladder neck
contracture
Urgency/frequency may persist
SURGERY, cont.
 Transurethral Incision of the Prostate
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Faster, less morbid than TURP
Requires right prostate anatomy (small gland)
Higher rate of reoperation vs. TURP
But less incidence of stricture, incontinence,
retrograde ejaculation
SURGERY, cont.
 Open Prostatectomy
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When gland too large to treat otherwise
Bladder stones, diverticula
 Minimally Invasive Procedures
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Laser, needle ablation, electrovaporization,
hyperthermia, ultrasound
Need RCT, long-term follow-up
 Intraurethral stents
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Patients with short life expectancy, high risk
REFERENCES AND READINGS
 Lieber MM. Mayo Clin Proc 1998;73:590-
596.
 McConnell JD et al. NEJM 2003;349:23872398.
 Stoller ML, Carroll PR. Urology. Chapter 23
in: Tierney LM Jr, McPhee SJ, Papadakis
MA, Current Medical Diagnosis & Treatment,
2004, McGraw-Hill.
 Thompson IM et al. NEJM 2003;349:215224.
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.