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Canadian Undergraduate Urology Curriculum ( CanUUC ): Prostate Diseases

Canadian Undergraduate Urology Curriculum ( CanUUC ): Prostate Diseases. Last reviewed May 2017. Prostate 1: LUTS/ Benign Prostate Hyperplasia. Objectives. D escribe the lower urinary tract symptoms (LUTS) found in men with BPH.

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Canadian Undergraduate Urology Curriculum ( CanUUC ): Prostate Diseases

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  1. Canadian Undergraduate Urology Curriculum (CanUUC):Prostate Diseases Last reviewed May 2017

  2. Prostate 1: LUTS/Benign Prostate Hyperplasia

  3. Objectives • Describe the lower urinary tract symptoms (LUTS) found in men with BPH. • Outline the investigations required when evaluating a man with LUTS. • Describe the medical treatments of BPH. • Describe the indications for surgical treatment of BPH.

  4. Benign Prostatic Hyperplasia • Commonly associated with “voiding” & urinary “storage” symptoms • Epidemiology • Extremely common with 70% of men in their 70’s describing voiding symptoms

  5. Benign Prostatic Hyperplasia: Pathophysiology • Pathophysiology • Prostate volume increases from puberty • Androgen dependent • Symptoms correlate with gland size, but not strongly • Static compression of the urethra • Glandular volume • Dynamic compression of the urethra • Smooth muscle component of prostate stroma Hypertrophied detrusor muscle Obstructed urinary flow

  6. Lower Urinary Tract Symptoms (LUTS) • Storage Symptoms • Frequency • Urgency ± urge incontinence • Nocturia • Voiding Symptoms • Hesitency • Decreased stream • Straining to void • Incomplete emptying • Urinary retention • Overflow incontinence *LUTS does not equate to BPH but BPH is the most common cause of LUTS*

  7. Differential Diagnosis of LUTS • Multiple problems can co-exist • Pre-Prostatic Causes • Stones/Tumors • Infections/inflammatory conditions • Neurogenic Bladder (spinal cord injuries, MS, Diabetes, etc) • Atonic Bladder /Overactive Bladder • Polyuria/Polydypsia • Prostatic Causes • BPH • Prostatitis • Prostate Cancer (advanced) • Post-Prostatic Causes • Urethral Stricture • Meatal Stenosis

  8. Evaluation:Medical History Medical History • Should focus on: • Urinary tract symptoms • UTI, Hematuria • Previous surgery • Family history of prostate carcinoma • Co-morbidities/general health issues • Medications (Anti-cholinergics & sympathomimetics) • Voiding diary (optional)

  9. Evaluation:Physical Examination Physical Examination • Complete exam including: • Abdomen (assess bladder) • External genitalia • Focused neurological exam • Digital Rectal Examination (DRE) • (Assess for concurrent disease)

  10. BPH:Recommended Investigations • Urinalysis and culture • Prostate Specific Antigen (PSA)(if appropriate) • International Prostate Symptom Index (or AUA symptom index) • Serum Creatinine (optional)

  11. American Urological Association Symptom Index (AUA-SI) Incomplete bladder emptying Frequency Intermittency Urgency Weak stream Straining Nocturia AUA Practice Guidelines Committee. J Urol. 2003;170(2 pt 1):530537. Barry MJ et al. J Urol. 1992;148:15491557.

  12. LUTS:Optional Investigations • Cystoscopy (only if): • If urinalysis abnormal (hematuria or pyuria) • Patient <50 years old • Renal Ultrasound (only if): • If serum Cr elevated • PVR urine/Uroflow (optional) • Urodynamic’s (if) • Patient <50 years old • Atypical symptoms or neurologic disease • Incontinence (male)

  13. LUTS:Treatment Options • Lifestyle Measures • Watchful Waiting • Medical Management • Alpha blockers • 5-alpha reductase inhibitors (5 ARI’s) • PDE5 inhibitors (Tadalafil 5mg poqDay) • Surgical Management

  14. 1. Treatment Options:Lifestyle Measures • Fluid modification • Reduce fluid intake in the evening • Avoid caffeine, alcohol • Timed voiding • Regular timed voiding of the bladder • Modify medications • I.e: change time of dosing diuretics • Avoid cold remedies (anti-histamines) • Avoid anti-cholinergics • Avoid alpha-agonists (i.e. decongestants)

  15. Treatment Options:Herbal Supplements Herbal:Commonly available OTC supplements • Saw palmetto extract (Serenoarepens) (Recent NEJM Paper cited no proven benefit) • Pumpkin seed (no evidence) • Pygeumafricanum (African Plum) Mineral: • Zinc (however, no proven benefit) • Wilt TJ, et al. JAMA. 1998;280:1604-9; • Barry MJ. BMJ. 2001;323:1042-6.

  16. 2. Treatment Options:Watchful Waiting Watchful Waiting: • Patient monitored by physician without active intervention for LUTS • Safe in patients with mild, stable symptoms • Intervene when symptoms worsen or complications arise such as acute retention, recurrent hematuria, recurrent UTI, hydronephrosis, bladder calculi

  17. 3a. Medical Treatment: Long-acting Non-selective 1-blockers • The prostate has a muscular “dynamic” component (centrally) • These fibers are alpha-receptor mediated

  18. 3a. Medical Treatment: Long-acting Non-selective 1-blockers • Dosage is increased in a stepwise fashion at weekly intervals • Does not affect PSA • Acts to relax prostatic/bladder neck smooth muscle (& vascular smooth muscle - non selective) • Doxazosin (Cardura) • Dosage: 1-2 mg qDay, titrate up to 4-8 mg OD • Terazosin (Hytrin) • Dosage: 1 mg OD, titrate up to 2, 5, or 10 mg • Not usually first line anymore

  19. 3a. Medical Management:Long-acting Selective 1A-blockers Long-acting selective 1-blockers • Specifically relaxes the smooth muscle of the prostate and bladder neck • Does not interfere with bladder contractility • Does not affect PSA • Alfuzosin (Xatral) • Dosage: 10 mg qDay • Tamsulosin(Flomax) • Dosage: 0.4 mg qDay • Silodosin (Rapaflo) • Dosage: 8mg qDay

  20. 1-Blockers:Side Effects • 5 known side effects of alpha blockade for LUTS • Asthenia • Hypotension • Retrograde ejaculation • Dizziness • Flu-like syndrome

  21. 3b. Medical Management: The 5--reductase Inhibitors 5--reductase inhibitors: • Regulate androgen available to prostate by blocking conversion of testosterone to dihydrotestosterone (DHT) • Slow the rate of prostate enlargement • Reduce prostate volume and relives “static” compression by BPH • Reduce PSA by ~50% • Takes 3-6 months to exert clinical effect

  22. 5--reductase Inhibitors • Men with larger prostates (> 40 g) respond most favorably • Finasteride(Proscar) • Dosage: 5 mg OD – type II inhibitor • Dutasteride(Avodart) • Dosage: 0.5 mg OD – type I and II inhibitor

  23. 5--reductase Inhibitors:Side Effects *percentages reflect upper estimates of incidence

  24. 3c. Medical Management: Daily PDE5 Inhibitor Tadaladfil 5mg qDay: • Improvesmale LUTS • Exact mechanism unknown • Helps concurrent erectile dysfunction • May potentiate hypotension in men taking concurrent alpha-blockers

  25. 4. LUTS:Indications for Surgery • Bothersome symptoms despite treatment • BPH-related complications • Urinary Retention (inability to void) • Bladder calculi • Recurrent UTI • Recurrent hematuria from the prostate • Upper tract dysfunction (hydronephrosis, renal dysfunction) • Surgical approach will depend on: • Patient’s prostate size • Surgeon’s judgment • Patient’s co-morbidities

  26. BPH Surgery:Transurethral Resection of Prostate (TURP) is the Most Common Surgery for BPH • Transurethral resection of the prostate (TURP) • Standard of care • Uses electrosurgeryto “core” out the obstructive tissue

  27. LUTS:Surgical Techniques TURP - Transurethral Resection of Prostate • Gold standard for surgical treatment of BPH if prostate has moderate size Minimally invasive surgeries • Numerous laser vapourization techniques Open prostatectomyto remove the central/transtion zone when prostate is very large (>100cc)

  28. Complications: TURP • Retrograde ejaculation (very common>90%) • Incontinence (1-2%) • Erectile Dysfunction (rare) • Bladder neck Contracture/Urethral Stricture (1-10%) • Bleeding (~5% need a transfusion) • Risks of any Operation

  29. Treatment of BPH:Summary • Watchful Waiting • Patients with mild symptoms • Alpha Blocker • Relaxes prostatic smooth muscle • Rapid relief of symptoms (within 2 weeks) • May not address eventual progression • 5--reductase inhibitor • Decreases prostate volume • “Slower” acting (3-6 months) • May reduce risk of progression • More suitable for larger prostates • Combination Therapy

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