BPH Diagnosis and Medical Treatment

1. BPHDiagnosis and Medical Treatment

2. 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

3. LUTS • Morbidity & Complication of BPH • Mortality of BPH : Rare • LUTS : Bothersome Highly variable • Treatment : Patient’s perception Degree of interfering life style

4. 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

5. LUTS • Irritative versus Obstructive • Irritative • Frequency/urgency/nocturia • Obstructed • Slow stream/stranguria/start-stop • Difficult to distinguish by history alone since symptoms overlap

6. Initial Evaluation • History • DRE & Focused PE • UA • PSA in select patients AUA/IPSS Sx Index, Bother

7. Medical History • Surgery, general health • Voiding History: polyuria, stranguria, frequency, urgency post void dribbling • Voiding diary (nocturia) • Urinary Infections :culture • Incontinence

8. Physical Examination • DRE • Neurologic exam • Mental status • Ambulatory status • Neuromuscular function • Anal sphincter tone

9. Urinalysis • Bladder cancer, CIS • UTI, Urethral stricture • Urethral, bladder stones

10. 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

11. 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

12. 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

13. 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

15. QOL

16. 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

17. Qmax : rate of urine flow • Predict the response to surgery • Predict the natural Hx of BPH Advantages • LUTS with Normal Qmax : non prostatic cause • Qmax < 10ml/sec : obstruction Disadvantages • Sx response is not dependent on Qmax • Test / retest variability, lack of well designed study → Not feasible to establish cut-point

18. 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

19. 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

20. CMG, IVP, USG of Kidney • Not recommended • Indicated in Hematuria, UTI • Renal insufficiency, stone Hx, upper tract surgery Hx

22. Initial Management and Discussion of Treatment Options • Watchful waiting • Medical therapy – pills • Minimally invasive surgery • Surgery

24. 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 Sx flow rate, AUR, surgery

25. Medical Treatment Options • Alpha-adrenergic blockers • 5 alpha-reductase inhibitors • Combination therapies • Phytotherapy

26. 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

27. 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)

28. 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

32. Natural History of BPH • PLESS study 1. 3,040 clinical BPH patients 2. IPSS: moderate to severe 3. Qmax: <15 ml/s 4. DRE: enlarged prostate gland 5. PSA <10 ng/ml (PSA 4-9.9: negative biopsy) 6. Follow-up: 4 years

33. Natural History of BPH • Risk of Acute Urinary Retention or Surgery

34. Natural History of BPH • Change of Symptom Score

35. Natural History of BPH • Change of Peak Urinary Flow Rate

36. Surgery • Minimally Invasive (office) • Microwave • TUNA • Interstitial Laser • Surgery (operating room) • TURP • HOLAP • HOLEP

37. 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

38. Surgery • Absolute Indications • Retention • Repeated infection • Bladder stones • Relative indications • Worsening symptoms • Rising urine retention • Desire to stop medication

39. 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

40. 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

41. Surgery • Indicated for urine retention • Highest side effects • Possible incontinence • Retrograde ejaculation • Best treatment outcomes • Improves flow rate • Lowers voiding symptoms

42. 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