Kashifuddin Qayoom SoomroKashifuddin Qayoom Soomro

Assistant ProfessorAssistant ProfessorDepartment of UrologyDepartment of Urology

Liaquat University of Medical & Health Sciences Liaquat University of Medical & Health Sciences JamshoroJamshoro

BPH – From Diagnosis To Treatment Strategies in GP Practice

The most common benign tumor in The most common benign tumor in men.men.

Half of all men over the age of 60 Half of all men over the age of 60 will develop an enlarged prostatewill develop an enlarged prostate

By the time men reach their 70’s and By the time men reach their 70’s and 80’s, 80% will experience urinary 80’s, 80% will experience urinary symptomssymptoms

n

n

BPH and prevalenceBPH and prevalence

BPH is a very frequent BPH is a very frequent conditioncondition

in ageing men in ageing men

0%

20%

50%

90%

< 30 years 41-50 years 51-60 years > 80 years

Prevalence of BPH

What causes BPH?What causes BPH?

BPH is part of the BPH is part of the natural aging process, natural aging process, like getting gray hair or like getting gray hair or wearing glasseswearing glasses

BPH BPH cannotcannot be be

preventedprevented

BPH BPH cancan be treated be treated

n

n

The lower urinary tract The lower urinary tract symptoms (LUTS)symptoms (LUTS)

BPHBPH

Bladder Outlet Obstruction (BOO)Bladder Outlet

Obstruction (BOO)

Impaired detrusorcontractility

Impaired detrusorcontractility

Involuntarybladder

contraction

Involuntarybladder

contraction

• Voiding symptoms- hesitancy

- weak stream

- prolonged voiding

- post voiding dribbling

- feeling of incomplete emptying

• Decreased flow rates

• Post void residual urine

• Voiding symptoms- hesitancy

- weak stream

- prolonged voiding

- post voiding dribbling

- feeling of incomplete emptying

• Decreased flow rates

• Post void residual urine

• Storage symptoms- urge

- frequency

- nocturia

- urge incontinence

• Storage symptoms- urge

- frequency

- nocturia

- urge incontinence

BPH/LUTS is largely BPH/LUTS is largely undertreatedundertreated

2

11

34

4

19

45

7

26

48

0

20

40

60

80

100

50 - 59 60 - 69 70 - 79

Percentage of men who receive medical treatment for their LUTS by LUTS severity

LUTS

Age

Rosen et al. Eur Urol 2003; 44: 637- 49

The Diagnosis The Diagnosis of BPHof BPH

The patient’s initial The patient’s initial evaluationevaluation

The basic evalution should be done on every patient presenting to a health care provider with LUTS: Medical history Assessment of symptoms

and bother Physical examination (DRE) Urinalysis Serum Prostate-Specific Antigen

(PSA)* Frequency-Volume Chart (to differentiate

between nocturia and polyuria)

*not in all patients

The medical history of the The medical history of the patientpatient

Nature and duration of LUTS

Previous surgical procedures

General health issues, sexual function history

Medications currently taken bythe patient

The patient’s fitness for possible surgical procedures or other treatments

The International Prostate The International Prostate Symptom Score (IPSS)Symptom Score (IPSS)

The I-PSS is based on the answers to 7 questions The I-PSS is based on the answers to 7 questions concerning urinary symptoms.concerning urinary symptoms.

Each question is assigned points from 0 to 5 indicating Each question is assigned points from 0 to 5 indicating increasing severity.increasing severity.

The total score can therefore range from 0 to 35 The total score can therefore range from 0 to 35 (asymptomatic to severely symptomatic).(asymptomatic to severely symptomatic).

MildMild 0-70-7

ModerateModerate 8-198-19

SevereSevere 20-3520-35

Patient name:Patient name:DateDate

1. Incomplete emptying1. Incomplete emptyingOver the past month, how oftenOver the past month, how oftenhave you had a sensation of nothave you had a sensation of notemptying your bladder completelyemptying your bladder completelyafter you finish urinating?after you finish urinating?

2. Frequency2. FrequencyOver the past month, how often Over the past month, how often have you had to urinate again lesshave you had to urinate again lessthan two hours after you finishedthan two hours after you finishedurinating?urinating?

3. Intermittency3. IntermittencyOver the past month, how often Over the past month, how often have you found you stopped andhave you found you stopped andstarted again several times when started again several times when you urinated?you urinated?

Less than1 time in 5

Not at all Less than half in the

time

About half the

time

More than half the

time

Almostalways

0 1

0

0

1

1

2

2

2

3

3

3

4

4

4

5

5

5

The International Prostate The International Prostate Symptom Score (1)Symptom Score (1)

Patient name:Patient name:DateDate

4. Urgency4. UrgencyOver the past month, how often have you Over the past month, how often have you found it difficult to postpone urination?found it difficult to postpone urination?

5. Weak stream5. Weak streamOver the pas month, how often haveOver the pas month, how often haveyou had a weak urinary stream?you had a weak urinary stream?

6. Straining6. StrainingOver the past month, how often haveOver the past month, how often haveyou had to push or strain to begin to you had to push or strain to begin to urinate?urinate?

7. Nocturia7. NocturiaOver the past month, how many times Over the past month, how many times did you most typically get up to urinate did you most typically get up to urinate from the time you went to bed until the from the time you went to bed until the time you got up in the morning?time you got up in the morning?

Less than1 time in 5

Not at all Less than half in the

time

About half the

time

More than half the

time

Almostalways

0 1

0

0

1

1

2

2

2

3

3

3

4

4

4

5

5

5

0 1 2 3 4 5

The International Prostate The International Prostate Symptom Score (2)Symptom Score (2)

Patient name:Patient name:DateDate

1. If you were to spend the rest1. If you were to spend the restof your life with your urinaryof your life with your urinarycondition just the way it is now, condition just the way it is now, how would you feel about that?how would you feel about that?

Pleased Delighted Mostly satisfied

Mixedabout

equally satisfied

and dissatisfied

Unhappy Terrible

0 1 2 3 4 5

BOTHER SCORE (BS) =

The bother score (IPSS 8th The bother score (IPSS 8th question)question)

Disease specific quality of life Disease specific quality of life and sexual functionand sexual function

No recommended questionnaire in routine No recommended questionnaire in routine practicepractice

Sexual function questionnaires used Sexual function questionnaires used exclusively in clinical trials (IIEF, DAN-exclusively in clinical trials (IIEF, DAN-PSSsex, BSFI, MSHQ…) PSSsex, BSFI, MSHQ…)

The physical examinationThe physical examination

1. Abdominal examination

rule out other possible urinary or rectal conditions

2. Digital Rectal Examination(DRE)

fundamental method for assessing the shape and the volume of the prostate

UrinalysisUrinalysis

Standard examination for the detection of:Standard examination for the detection of:

- Haematuria,- Haematuria,

- Proteinuria,- Proteinuria,

- Pyuria, - Pyuria,

4-5% of men with microscopic haematuria will be 4-5% of men with microscopic haematuria will be found to have a cancer or other urological disease found to have a cancer or other urological disease within the first 3 years following the test.within the first 3 years following the test.

Serum Prostate-Specific Serum Prostate-Specific Antigen (PSA)Antigen (PSA)

Measurement recommended for patients with at Measurement recommended for patients with at least 10-year life expectancy and for whom least 10-year life expectancy and for whom knowledge of the presence of prostate cancer knowledge of the presence of prostate cancer would change managementwould change management

PSA is also a proxy of prostate size but its PSA is also a proxy of prostate size but its variability is high. Recent studies suggest that it variability is high. Recent studies suggest that it may be used to predict the risk of AUR and may be used to predict the risk of AUR and BPH-related surgery.BPH-related surgery.

Frequency - volume chartFrequency - volume chart

Measurement useful when nocturia is the Measurement useful when nocturia is the predominant symptompredominant symptom

To identify patients with nocturnal polyuria To identify patients with nocturnal polyuria excessive fluid intakeexcessive fluid intake

BPH TreatmentsBPH Treatments

1. Provide rapid and sustainedrelief of symptoms.

2. Act on the course of thedisease by preventing long-term complications.

3. Respect patients’ Quality of Life and sexual function.

Treatment objectivesTreatment objectives

The BPH patient is basically The BPH patient is basically offered 3 treatment options:offered 3 treatment options:

SurgerySurgeryWatchful WaitingWatchful Waiting

Medical TreatmentMedical Treatment

The patient is instructed on behavioural techniques to reduce symptoms (reduction of fluid intake at bedtime, reduction of alcohol and caffeine consumption…).

The patient’s symptoms and clinical course should be monitored, usually annually.

Definition of watchful waitingDefinition of watchful waiting

Indications of watchful Indications of watchful waitingwaiting

Uncomplicated BPHUncomplicated BPH

Symptoms not bothersome (usuallySymptoms not bothersome (usuallyIPSS ≤7)IPSS ≤7)

Symptoms significantly bothersomeSymptoms significantly bothersomebut after being informed of various but after being informed of various treatment options and their consequences, treatment options and their consequences, the patient chooses watchful waitingthe patient chooses watchful waiting

Indications of medical Indications of medical treatmenttreatment

Uncomplicated BPHUncomplicated BPH

Symptoms are bothersome (usually Symptoms are bothersome (usually IPSS>7) and after being informed of IPSS>7) and after being informed of various treatment options and their various treatment options and their consequences, the patient chooses consequences, the patient chooses medical treatmentmedical treatment

There are 2 pharmacological There are 2 pharmacological classes used in BPHclasses used in BPH

1-blockers1-blockers5-reductase inhibitors5-reductase inhibitors

The 2 components of BOOThe 2 components of BOO

Dynamic Component

Increase inprostate bulk

Increase insmooth muscle tone

Normal Hyperplastic

Static Component

By inhibiting the production of DHT, they are expected to reduce the size of the prostate.

55-reductase inhibitors act on-reductase inhibitors act onthe static component of BOOthe static component of BOO

But …But …

Delayed onset of actionDelayed onset of action Need 6 to 12 months to significantly improve Need 6 to 12 months to significantly improve

LUTSLUTS Less effective than α1-blockade on LUTSLess effective than α1-blockade on LUTS

Improve IPSS of 3 to 4 pointsImprove IPSS of 3 to 4 points More effective for enlarged prostates More effective for enlarged prostates

(> 40g)(> 40g)

They are sparse in the bladder body

11-receptors are abundant in the-receptors are abundant in the

bladder neck, prostate and urethrabladder neck, prostate and urethra

11-blockers-blockers are expected to reduce the sympathetic tone of the

prostate and the urethra.

11-blockers act on the dynamic -blockers act on the dynamic

component of BOOcomponent of BOO

11-blockers may have local-blockers may have local

but also systemic effectsbut also systemic effects

Prostate Urethra

Bladder Neck

Prostate Urethra

Bladder Neck

Outflowresistance

Outflowresistance

FlowRates

FlowRates

VoidingSymptoms

VoidingSymptoms

Residual Urine

Residual Urine

Filling Symptoms

Filling Symptoms

BladderBladder

Blood vesselsBlood vessels

BladderInstability

BladderInstability

Blood Pressure

Blood Pressure

Postural Hypotension

Dizziness

Postural Hypotension

Dizziness

URINARY TRACT EFFECT

SYSTEMIC EFFECT

Uroselectivity is the capacity to Uroselectivity is the capacity to achieve more local than systemic achieve more local than systemic

effectseffects

Uroselective (new generation)

1-blockers mainly effective on the lower

urinary tract

Uroselective (new generation)

1-blockers mainly effective on the lower

urinary tract

Non-uroselective(old generation)

1-blockers primarily developed for the

treatment of hypertension

Non-uroselective(old generation)

1-blockers primarily developed for the

treatment of hypertension

New generation (uroselective) New generation (uroselective) 11-blockers-blockers

Terazosin (HYTRIN)DoxazosinAlfuzosin

Tamsulosin

Recent molecules

Few cardiovascular & CNS side effects

1Marks et al. Urology 2003, 62, 888-8932Lepor Urology 1998, 51, 892-9003AUA Practice Guidelines Committee, J.Urol 2003, 170, 530-547

Benefits of Benefits of 11-blockers in BPH-blockers in BPH Rapid onset of action Rapid onset of action

From the first dose on peak flow rate for From the first dose on peak flow rate for terazosin ( Hytrin ), alfuzosinterazosin ( Hytrin ), alfuzosin1 1 and tamsulosinand tamsulosin22, ,

From the first days on LUTSFrom the first days on LUTS Best monotherapy for relief of LUTSBest monotherapy for relief of LUTS33

Improvement of IPSS of 4 to 6 pointsImprovement of IPSS of 4 to 6 points Effective irrespective of prostate sizeEffective irrespective of prostate size Improve quality of life and respect sexual Improve quality of life and respect sexual

functionfunction

1McNeill et al. Urology 2005, 65, 83-902McConnell et al. NEJM 2003, 349, 2387-983Roehrborn et al., BJU Int 2006, 97, 734-741

Benefits of Benefits of 11-blockers in BPH-blockers in BPH

Facilitate catheter removal with return to normal Facilitate catheter removal with return to normal voiding in men with AURvoiding in men with AUR11

Reduce BPH progressionReduce BPH progression:: Terazosin ( Hytrin ), Alfuzosin and doxazosin do not Terazosin ( Hytrin ), Alfuzosin and doxazosin do not

prevent the occurrence of AURprevent the occurrence of AUR2-32-3.. However, Terazosin ( Hytrin ) alfuzosin and doxazosin However, Terazosin ( Hytrin ) alfuzosin and doxazosin

significantly reduce deterioration of LUTS compared significantly reduce deterioration of LUTS compared with placebowith placebo2-32-3. .

Complicated BPHComplicated BPH

Bladder stones Bladder stones Recurrent haematuriaRecurrent haematuria Acute Urinary RetentionsAcute Urinary Retentions Damage to kidneys Damage to kidneys Urinary tract infections Urinary tract infections

Surgical Surgical TreatmentsTreatments

Open prostatectomyOpen prostatectomy Transurethral Resection of the Prostate Transurethral Resection of the Prostate

(TURP)(TURP) Transurethral Incision of the Prostate Transurethral Incision of the Prostate

(TUIP)(TUIP) Transurethral Microwave Transurethral Microwave

Thermotherapy (TUMT)Thermotherapy (TUMT) Transurethral vaporization of the Transurethral vaporization of the

prostate (TUVP)prostate (TUVP) Transurethral needle ablation of the Transurethral needle ablation of the

prostate (TUNA)prostate (TUNA)

CONCLUSIONCONCLUSION

Every male > 50 yrs of age should be Every male > 50 yrs of age should be evaluatedevaluated

To exclude possibility of Ca prostate To exclude possibility of Ca prostate

To exclude complication resulting from To exclude complication resulting from BPHBPH

To improve the quality of life of patients To improve the quality of life of patients having LUTS with medical therapyhaving LUTS with medical therapy

ThanksThanks