Benign Prostatic Hyperplasia

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Benign Prostatic Hyperplasia

• Anoop Agrawal, M.D.
• Baylor College of Medicine
• Med-Peds Continuity Clinic

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Prevalence of BPH
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AUA BPH Algorithm
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Medical History

• Seven cardinal symptoms
• urinary frequency
• nocturia
• urgency
• hesitancy
• weak
• straining to void
• sensation of incomplete voiding

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Initial Evaluation

• History
• Digital Rectal Exam Focused Physical
• Urinalysis
• PSA
• AUA Symptom Index Score

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BPH Diagnosis

• Palpable prostate size does not correlate with a
  diagnosis of BPH, nor with degree of obstruction
  or the severity of symptoms.
• Use urinary symptom scoring scale by the American
  Urological Association to aid with diagnosis.
• consists of seven questions - each question
  grades severity of each symptom

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Differential Diagnosis

• Diabetes
• UTI
• Neurogenic bladder
• Urethral strictures
• Cancer (bladder or prostate)
• Medication induced

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Laboratory Testing

• Urinalysis
• PSA
• Optional tests
• urinary flow rate measurements
• postvoid residual urine measurements
• pressure flow studies

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AUA Symptom Index
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AUA Symptom Index Interpretation

• Classification
• Mild 0-7
• Moderate 8-19
• Severe 20-35
• The AUA score needs to be put in the context of
  whether the condition is or is not bothersome.

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Treatment

• Studies have found that over a follow-up period
  of 2.6 to 5 years, 16 men had stable symptoms
  and 38 improved over time.
• Treatment choices must take into account
• Symptom Index Score
• Effect on quality of life

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Case One

• A 62 yo man reports nocturia, frequency and
  urgency. His UA is negative, PSA is normal. His
  AUA Severity Index is 10. He states the symptoms
  are not very bothersome. What treatment options
  do you recommend?
• A. Watchful waiting
• B. alpha-1 blocker
• C. 5-alpha reductase inhibitor
• D. Surgical therapy

13
Case One

• A 62 yo man reports nocturia, frequency and
  urgency. His UA is negative, PSA is normal. His
  AUA Severity Index is 10. He states the symptoms
  are not very bothersome. What treatment options
  do you recommend?
• A. Watchful waiting
• B. alpha-1 blocker
• C. 5-alpha reductase inhibitor
• D. Surgical therapy

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Treatment

• Though symptom score may be above the Mild range
  (0-7), initiating medical therapy is not
  warranted unless patient finds he is bothered by
  the symptoms.
• May begin with behavior modifications
• reducing fluid intake at night
• reducing consumption of mild diuretics (caffeine
  and alcohol)

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Treatment

• Alpha-1 Blockers - common first line agent
• Rapid onset, reduction in symptom score by 30-40
• Nonselective Alpha-1 Blockers
• SE dizziness, orthostatic hypotension, fatigue,
  asthenia occurs in 7-9
• Selective Alpha Blocker (tamsulosin, alfuzosin) -
  less anti-hypertensive effect

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Case Two

• A 59 yo male presents with symptoms of BPH. His
  rectal exam reveals a enlarged prostate. You
  estimate at least 40 grams in size. His AUA
  score is 16. He reports the symptoms are very
  bothersome. What treatment options do you
  recommend?
• A. Watchful waiting
• B. alpha-1 blocker
• C. 5-alpha reductase inhibitor
• D. Surgical therapy

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Case Two

• A 59 yo male presents with symptoms of BPH. His
  rectal exam reveals a enlarged prostate. You
  estimate at least 40 grams in size. His AUA
  score is 18. He reports the symptoms are very
  bothersome. What treatment options do you
  recommend?
• A. Watchful waiting
• B. alpha-1 blocker
• C. 5-alpha reductase inhibitor
• D. Surgical therapy

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Treatment Case Two

• 5-alpha reductase inhibitors (finasteride,
  dutasteride) these require long-term treatment
  (6-12 months) before symptom improvement is seen
• more effective in men with large prostate
• Combination therapy with alpha-1 blocker and
  5-alpha reductase inhibitors
• found to be effective in men with severe symptoms
  or men with moderate symptoms and large prostate
• Downside is that long-term safety of finasteride
  is unknown

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Combination Therapy in BPH
McConnell, JD, Roehrborn, CG, Bautista, OM, et
al. The long-term effect of doxazosin,
finasteride, and combination therapy on the
clinical progression of benign prostatic
hyperplasia. N Engl J Med 2003 3492387
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Case Three

• A 65 yo man with moderate symptoms of BPH is
  worried about side effects from alpha-1 blockers
  and wants to know if any herbal remedies are
  recommended. What do you advise?

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Case Three

• Complementary Medicine options
• Genistein - an isoflavone found in tofu/soy
  products, found to decrease growth of
  hyperplastic prostate tissue in histoculture,
  marketed as Trinovin, dose 40 to 80mg qd.
• Saw palmetto - few side effects, safe, dosage is
  160mg bid
• A 2006 prospective trial found no improvement in
  symptoms. Current recommendation is to avoid.

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Case Four

• A 55 yo man has been experiencing chronic
  intermittent hematuria for past several months.
  Urology performed a flexible cystoscopy revealing
  no evidence of malignancy or atypia. PSA is
  normal. What treatment option is available to
  suppress gross hematuria?
• Finasteride - randomized trial of 57 men had
  lower rate of recurrent hematuria (14 vs 63)

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Surgical Treatments

• Open prostatectomy
• Transurethral Resection of the Prostate (TURP)
• Transurethral Incision of the Prostate (TUIP)
• Transurethral Microwave Thermotherapy (TUMT)
• Transurethral vaporization of the prostate (TUVP)
• Transurethral needle ablation of the prostate
  (TUNA)

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AUA BPH Algorithm
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Conclusion

• Diagnosis based upon patients symptom index and
  affect on quality of life
• Wide range of treatment options - discuss with
  patient benefits and risks.
• Surgical therapy tends to be more effictive, but
  results in more residual side effects.

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References

• Bent S, et al. Saw Palmetto for Benign Prostatic
  Hyperplasia. NEJM 2006 354557-566.
• Dull P, et al. Managing Benign Prostatic
  Hyperplasia. Am Fam Physician 20026677-84.
• UpToDate 2009 Medical Treatment of benign
  prostatic hyperplasia. (Accessed February 21
  22, 2009).