BPHDiagnosis 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 perceptionDegree 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

Frequency/urgency/nocturia Obstructed

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 BPHAdvantages LUTS with Normal Qmax : non prostatic

cause Qmax < 10ml/sec : obstructionDisadvantages 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

Sxflow rate, AUR, surgery

Medical Treatment Options

1. Alpha-adrenergic blockers2. 5 alpha-reductase inhibitors3. Combination therapies4. 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 patients2. IPSS: moderate to severe3. Qmax: <15 ml/s4. DRE: enlarged prostate gland5. 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