Medical management of BPH

1. Medical Management of BPH
Omar S. Akhtar,
Urology Registrar

2. What is BPH?
● Benign prostatic hyperplasia (BPH), also known as is
a histologic diagnosis characterized by proliferation of
the cellular elements of the prostate
● Per se, it is not the enlargement of the prostate, but the
Bladder Outlet Obstruction (BOO) secondary to it that
is the cause of worry
● These may include, recurrent infections, back-pressure
changes, leading to renal insufficiency, gross
haematuria, etc.

3. Presentation
● Incomplete emptying
● Frequency
● Intermittency
● Urgency
● Weak stream
● Straining
● Nocturia

6. Medical Management
● Goals: reduce symptoms

7. Management Strategy
● Essential word: BOTHER
● AUA-SI score <8, or AUA-SI score >/= 8,
with NO BOTHER: WATCHFUL WAITING
o Re-examine: annually
● Those with AUA-SI >8: treat, treat, treat

8. Medication Types
● Alpha-blockers - Selective/Non-selective
● 5-Alpha reductase inhibitors
● Phosphodiesterase inhibitors

9. Mechanisms of Action

10. Alpha Blockers
● Significant contribution to LUTS from smooth
muscle tension in the bladder neck, urethra,
prostate stroma
● Mediated by alpha-adrenergic receptors
● Three subtypes: A-1a, A-1b, A-1c
● A-1a, is most abundant in prostate tissue
● Drugs targeting blockade of A-1a, are used for
BPH

11. Alpha Blockers - Types
● Nonselective alpha-blockers - phenoxybenzamine
● Selective short-acting alpha-1 blockers - prazosin,
alfuzosin, indoramin
● Selective long-acting alpha-1 blockers - terazosin,
doxazosin, slow-release (SR) alfuzosin.
● Partially subtype (alpha-1a)–selective agents –
tamsulosin (Urimax), silodosin (Silodal)

12. Alpha Blockers - Effects
● AUA-SI score fall of 4-6 over 6 months
● In pts with mild LUTS, may be discontinued after 6
months, with severe LUTS, may require long-term
therapy
● Alpha blockers tend to show effect fast
● Must be individualised, due to side-effects
● CAUTION: young males, elderly pts with hypotension,
large prostates (>59 gms)
● Does NOT decrease the likelihood of AUR!!!

13. 5-Alpha Reductase Enzyme Inhibitors
● Enzyme used to activate Testosterone, reducing it to
active form (DHT)
● Two main types - Type 1, liver, skin and Type 2,
prostate
● Blockade of Type 2 - 5-Alpha-reductase, leads to
decreased prostatic growth, prostate involution,
apoptosis
● Finasteride (Type 2 Inhibitor), Dutasteride (Type 1 & 2
Inhibitor), are two examples

14. 5-Alpha Reductase Inhibitors - Effect
● Both finasteride and dutasteride actively reduce DHT
levels > 80%
● Improve symptoms,
● Reduce the incidence of urinary retention (PLESS)
● Decrease the likelihood of surgery
● Adverse effects: sexual in nature (decreased libido,
erectile dysfunction, ejaculation disorder)
● Reduce PSA levels by 50% in 1 year, important when
monitoring pts

15. PDE Inhibitors, Alternatives
● PDE inhibitors (Sildenafil) were shown to
improve LUTS secondary to BPH
● Evidence for their use in combination or
alone, is lacking
● Recent guidelines have not advocated their
use
● AUA 2010 Guideline states: ‘No dietary
supplement, combination phytotherapeutic
agent or other nonconventional therapy is
recommended for the management of LUTS
secondary to BPH.’ (Page 16)

16. Combination Therapy
- CombAT trial is underway: it has shown that for prostates
of 30-58 gms, with LUTS, combination therapy:
● improved symptoms,
● urinary flow,
● QOL
better than monotherapy with either drug, although not in
men who had a prostate volume of 58 mL or more

17. So where does this leave us?
● Key word: BOTHER
● If there is BOTHER, then TREAT
● Indications for Surgery - go for it
● Conservative: for small prostates,
start with alpha-blockers, selective A-
1a blockade x 6 months
● For larger prostates, start with
combination therapy, Dutas + Alpha-
Blockade