BPH is a common noncancerous enlargement of the prostate gland that increases in frequency with age in men over 50. By age 60, 50% of men will show microscopic signs of BPH, increasing to 90% by age 85. BPH causes lower urinary tract symptoms like frequent urination, weak urine stream, and incomplete emptying due to static obstruction from an enlarged prostate and dynamic obstruction from prostate smooth muscle contraction. Diagnosis involves evaluating symptoms, digital rectal exam to assess prostate size and consistency, urinalysis to rule out infection, and tests like uroflowmetry and post-void residual urine measurement to assess bladder function.

1. Benign prostatic hyperplasia
Dr Doha Rasheedy
Assistant professor
Geriatrics and Gerontology Department
ASU

2. • BPH is a common disorder that increases in
frequency progressively with age in men older
than 50 years and is hormonally dependent on
testosterone and dihydrotestosterone (DHT)
production.
• Microscopic appearance of BPH is present in 50%
of men by age 60
• Microscopic appearance of BPH is present in 90%
of men by age 85
• It is a noncancerous enlargement of the
epithelial and fibromuscular components of the
prostate gland.2/25/2018 2

3. • The voiding dysfunction that results from prostate
gland enlargement and bladder outlet obstruction
(BOO) is termed lower urinary tract symptoms
(LUTS).
• It has also been commonly referred to as
prostatism, although this term has decreased in
popularity.
• These entities overlap; not all men with BPH have
LUTS, and likewise, not all men with LUTS have
BPH.
• Approximately half of men diagnosed with
histopathologic BPH demonstrate moderate-to-
severe LUTS.
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4. PATHOPHYSIOLOGY
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5. LUTS and signs of BPH are due to
Static
Dynamic
Detrusor factors
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6. The static factor refers to:
• anatomic obstruction of the bladder neck
caused by an enlarged prostate gland.
• As the gland grows around the urethra, the
prostate occludes the urethral lumen.
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7. The dynamic factor refers to:
• excessive stimulation of α1A-adrenergic
receptors in the smooth muscle of the prostate,
urethra, and bladder neck, which results in
smooth muscle contraction.
• This reduces the caliber of the urethral lumen
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8. The detrusor factor refers to:
• bladder detrusor muscle hypertrophy in response to
prolonged bladder outlet obstruction.
• hypertrophy help the bladder to generate higher
pressure to overcome bladder outlet obstruction
and empty urine from the bladder.
• The hypertrophic detrusor muscle becomes irritable,
contracting abnormally in response to small
amounts of urine in the bladder.
• If obstruction is not treated, the bladder muscle will
decompensate and be unable to empty completely;
the postvoid residual urine volume (PVR) will
increase.2/25/2018 8

9. • Prostatic enlargement is influenced by a
combination of androgens, growth factors,
estrogens, and epithelial-stromal interactions
Dihydrotestosterone (DHT):
• In the prostate gland, type II 5-alpha-reductase
metabolizes circulating testosterone into DHT, which
works locally, not systemically. DHT binds to androgen
receptors in the cell nuclei, potentially resulting in
BPH.
• Androgens stimulate epithelial, but not stromal tissue
hyperplasia.
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10. • In an enlarged gland, the epithelial/stromal tissue
ratio is 1:5.
• Hence, androgen antagonism does not induce a
complete reduction in prostate size to normal. This
explains one of the limitations of the clinical effect of
5α-reductase inhibitors.
• Stromal tissue is the primary locus of α1-adrenergic
receptors in the prostate. An estimated 98% of the α-
adrenergic receptors in the prostate are found in
prostatic stromal tissue.
• Of the α1-receptors found in the prostate, 70% of
them are of the α1A- subtype and the remainder are
of the α1B and α1D subtypes.
• This explains why α-adrenergic antagonists are
effective for managing symptoms of BPH.
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11. CLINICAL PICTURE
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12. • The clinical manifestations of BPH are lower
urinary tract symptoms (LUTS)
• These symptoms typically appear slowly and
progress gradually over a period of years.
• LUTS are not specific for BPH.
• the correlation between symptoms and the
presence of prostatic enlargement on rectal
examination or by transrectal ultrasonographic
assessment of prostate size is poor.
2/25/2018 12

13. Causes of Male Lower Urinary Tract
Symptoms
• Benign prostatic enlargement (secondary to benign prostatic hyperplasia)
• Urinary tract infection
• Prostatitis
• Overactive bladder
• Neurogenic bladder dysfunction
• Urethral stricture
• Bladder neck contracture
• Phimosis
• Urinary tract stones
• Bladder tumor
• Advanced prostate cancer
• Foreign body in the bladder
• Medications, illicit drugs, and dietary factors (including caffeine, alcohol, ketamine,
and decongestants)
• Diabetes mellitus
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14. CATEGORIZATION OF LUTS
LUTS can be categorized as symptoms related to
storage,
voiding,
or post micturition
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15. Storage symptoms
Storage symptoms, experienced during the bladder
filling and storage phase of micturition, include:
• Urgency — A sudden compelling desire to pass
urine that is difficult to defer.
• Daytime frequency — A patient's perception that
he voids too often by day.
• Nocturia — The need to wake at night one or
more times to void.
• Urge incontinence — Involuntary leakage,
accompanied by, or immediately preceded by,
urgency.
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16. Voiding symptoms — Voiding symptoms are those experienced
at the time of urine flow and include:
Slow stream — The individual's perception of reduced urine
flow, usually compared to previous performance and
sometimes compared to observations of other men. Splitting or
spraying of the urine stream may be reported.
Intermittent stream or intermittency — Urine flow that stops
and starts, on one or more occasions, during micturition.
Hesitancy — Difficulty in initiating micturition, resulting in a
delay in the onset of voiding after the individual is ready to
pass urine.
Straining to void — An abdominal muscular effort used to
initiate, maintain, or improve the urinary stream.
Terminal dribble — Prolongation of the final part of
micturition, when the flow has slowed to a trickle/dribble .
Dysuria — Pain, burning sensation, or general discomfort at the
time of passing urine.2/25/2018 16

17. Post-micturition symptoms — Post-micturition
symptoms include:
• A sensation of incomplete emptying after
passing urine.
• Post-micturition dribble — The involuntary
loss of urine shortly following urination,
usually after leaving the toilet .
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18. • The term "lower urinary tract symptoms," or LUTS,
is nonspecific
• LUTS is also associated with severe sleep
disturbance , increased depressive symptoms and
decreased ability to perform activities of daily living
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19. DIAGNOSIS
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20. History
• Onset and duration of symptoms
• Severity of symptoms and how they are affecting
quality of life (the AUA symptom score- the
International Prostate Symptom Score (IPSS))
• General health issues (including sexual history)
• History of urethral trauma, urethritis, or urethral
instrumentation that could lead to urethral stricture
• Fitness for any possible surgical interventions
• Medications
• Previously attempted treatments
• Family history of BPH, Cancer prostate
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21. 2/25/2018 21
1. mild (total score 0 to 7),
2. moderate (total score 8 to 19)
3. severe (total score 20 to 35)

22. IPSS/AUA-SI
• The severity of BPH can be determined with the International Prostate
Symptom Score (IPSS)/American Urological Association Symptom Index
(AUA-SI) plus a disease-specific quality of life (QOL) question. Questions
on the AUA-SI for BPH concern the following:
• Incomplete emptying
• Frequency
• Intermittency
• Urgency
• Weak stream
• Straining
• Nocturia
• 0 to 7: Mild symptoms
• 8 to 19: Moderate symptoms
• 20 to 35: Severe symptoms
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23. Physical examination
1. Suprapubic area for signs of bladder distention
(dullness, tenderness)
2. The digital rectal examination
3. neurological examination for sensory and motor
deficits.(Decreased anal sphincter tone or the
lack of a bulbocavernosus muscle reflex may
indicate an underlying neurological disorder)
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24. Digital rectal examination
• prostate size, symmetry and contour can be
assessed, nodules can be evaluated
(nodularity more with benign BPH) , and areas
suggestive of malignancy can be detected.
• The normal prostate volume in a young man
is approximately 20 g.
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25. Laboratory studies
• Urinalysis - Examine the urine using dipstick methods and/or via
centrifuged sediment evaluation to assess for the presence of blood,
leukocytes, bacteria, protein, or glucose (DM- infection- heamaturia)
• Urine culture - This may be useful to exclude infectious causes of
irritative voiding and is usually performed if the initial urinalysis findings
indicate an abnormality
• Prostate-specific antigen - Although BPH does not cause prostate
cancer, men at risk for BPH are also at risk for this disease and should be
screened accordingly (although screening for prostate cancer remains
controversial)
• Electrolytes, blood urea nitrogen (BUN), and creatinine - These
evaluations are useful screening tools for chronic renal insufficiency in
patients who have high postvoid residual (PVR) urine volumes; however,
a routine serum creatinine measurement is not indicated in the initial
evaluation of men with lower urinary tract symptoms (LUTS) secondary
to BPH
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26. Ultrasonography
• Determine bladder and prostate size and the degree of
hydronephrosis (if any) in patients with urinary
retention or signs of renal insufficiency.
• Generally, they are not indicated for the initial
evaluation of uncomplicated LUTS.
• Abdominal, transrectal
• Transrectal ultrasonography (TRUS) of the prostate is
recommended in selected patients, to determine the
dimensions and volume of the prostate gland.
• In patients with elevated PSA levels, TRUS-guided
biopsy may be indicated.
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27. Flow rate:
1. (routine non invasive uroflowmetry)
2. For the results of uroflowmetry to be valid, the patient
needs to void more than 150 mL of urine.
3. Useful in the initial assessment and to help determine the
patient’s response to treatment
4. a low urine flow rate may indicate detrusor impairment or
BOO
5. A Qmax of less than 10 mL/sec is highly suggestive of BOO
PVR urine volume:
Used to gauge the severity of bladder decompensation; it can
be obtained invasively with by in-out catheterization or
noninvasively with a transabdominal ultrasonic scanner
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28. Urodynamic studies
1. to differentiate men with a low urine flow
rate caused by obstruction or impaired
bladder muscle contraction.
2. Pressure-flow studies also assess for
involuntary bladder muscle contractions
(detrusor overactivity) during the bladder
filling phase before voiding.
3. when considering surgery.
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29. Cystoscopy
• Indications:
– patients scheduled for invasive treatment
– suspected foreign body
– suspected malignancy.
– patients with a history of sexually transmitted
disease (eg, gonococcal urethritis)
– prolonged catheterization
– trauma.
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30. Cytologic examination of the urine
• May be considered in patients with predominantly
irritative voiding symptoms
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31. Basic management of lower urinary tract symptoms (LUTS) in men
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32. After initial evaluation
a man with LUTS suspected to have:
prostate cancer
hematuria
recurrent urinary tract infection
a palpable bladder
urethral stricture
a neurologic bladder disorder
should be referred to a urology clinic for
appropriate investigation and treatment.
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33. DIFFERENTIAL DIAGNOSIS
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34. Symptoms often attributed to benign prostatic hyperplasia
(BPH) can be caused by any of the following conditions:
1. Cystitis
2. Prostatitis
3. Prostatodynia
4. Prostatic abscess
5. Overactive bladder (OAB)
6. Carcinoma of the bladder
7. Foreign bodies in the bladder (stones or retained stents)
8. Urethral stricture due to trauma or a sexually transmitted
disease
9. Prostate cancer
10. Neurogenic bladder
11. Pelvic floor dysfunction
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35. COMPLICATIONS
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36. Complications of Untreated BPH
Very uncommon, So watchful waiting is allowed
1. Urinary retention (the incidence rate of acute
urinary retention was 14/1000 patient-years, The
risk factors for acute urinary retention include
advanced age, symptom severity, increased PSA
value, and prostate volume).
2. Urinary incontinence
3. Renal insufficiency
4. Recurrent urinary tract infections, urosepsis
5. Gross hematuria
6. Bladder calculi, bladder diverticula.
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37. MANAGEMENT
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38. Decision depend on
1. Severity
2. Comorbid conditions, frailty
3. Drug efficacy, side effects, duration of treatment
response.
• BPH therapy is patient-dependent and driven by the impact of
symptoms on the patient’s quality of life e.g. In men who are not
too bothered by their LUTS, simple reassurance and lifestyle
advice (in particular altering fluid intake) is often all that is
required
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39. 2/25/2018 39

40. Management
• Mild (0-7)________________ watchful waiting
• Moderate(8-19)_____________pharmacological
• Severe (20- 35)______________surgery
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41. Watchful waiting if:
1. Patients with mild symptoms (IPSS/AUA-SI score <7)
2. or moderate-to-severe symptoms (IPSS/AUA-SI score
≥8) of benign prostatic hyperplasia (BPH) who are not
bothered by their symptoms and are not experiencing
complications of BPH should be managed
Steps:
1. Reassurance: that their symptoms are not
secondary to cancer or other serious pathology
and that delaying active treatment will not have
irreversible consequences
2. Lifestyle modification
3. Re-examine 6-12 months, reassess AUA-SI
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42. Slide 42
LIFESTYLE MANAGEMENT OF BPH
Nonpharmacologic Therapy
(Behavioral Modification)
Interventions Comments
• Reduce night-time fluids to manage
nocturia
• Eliminate bladder irritants (eg,
caffeine, alcohol, nicotine)
• Avoid drugs (especially
anticholinergics) that aggravate
symptoms
• Postmicturition dribbling can be
improved with the simple technique
of urethral milking
• Often sufficient management for
mild symptoms
• Complements management for
moderate to severe symptoms
• fluid restriction, especially in the
evening can reduce both symptoms
and progression

43. 2/25/2018 43

44. Pharmacologic treatment
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45. Agents used in the treatment of BPH include
the following:
1. Alpha-adrenergic receptor blockers
2. 5-alpha reductase inhibitors
3. Anticholinergic agents
4. Phosphodiesterase-5 enzyme inhibitors
Drug treatment must be continued as long as
the patient responds
2/25/2018 45

46. Alpha-adrenergic receptor blockers
• α1-Blockers are first-line medical therapy for LUTS
secondary to BPH.
• α-Adrenergic antagonists are preferred over 5α-reductase
inhibitors because the former have a faster onset of action
(days to a few weeks) and improve symptoms
independent of prostate size
• α-Adrenergic antagonists are preferred for patients with
lower urinary tract voiding symptoms, who also have
small prostates (less than 30 g)
• Assess response after 2 weeks
• α1-blockers do not prevent BPH progression with the
associated risk of acute urinary retention and the need
for surgical intervention.
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47. Mechanism of action
• α-Adrenergic antagonists reduce the dynamic
factor causing BPH symptoms.
– These drugs competitively antagonize α-adrenergic
receptors, thereby causing relaxation of the bladder
neck, prostatic urethra, and prostate smooth muscle.
• A secondary mechanism of action may be that α-
adrenergic antagonists induce prostatic
apoptosis, which suggests that these agents may
cause some shrinkage of an enlarged prostate.
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48. Types:
• The alpha-blocking agents administered in BPH studies can
be subgrouped according to receptor subtype selectivity
and the duration of serum elimination half-lives, as
follows:
1. Nonselective alpha-blockers: phenoxybenzamine causing
irreversible blockade of long duration (14–48 hours or
longer)
2. Selective alpha-1 blockers:
1. short-acting: prazosin (minipress), alfuzosin, indoramin
2. long-acting: terazosin(hytrin), doxazosin (cardura), slow-
release (SR) alfuzosin.
3. uroselective subtype (α1A>>α1D >>> α1 B affinity in the
peripheral vasculature so less hypotension): tamsulosin,
silodosin:
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49. Pharmacodynamics
• α-Adrenergic antagonists are hepatically
metabolized. Therefore, in patients with
significant hepatic dysfunction, these drugs
should be used in the lowest possible dose.
• With the exception of silodosin, these drugs do
not require dosage modification in patients with
renal dysfunction.
• Despite the blood-pressure lowering property of
α-adrenergic antagonists, they are not
recommended to be used alone to treat patients
with both BPH and essential hypertension.
2/25/2018 49

50. Side Effects
1. Dizziness, syncope and orthostatic hypotension more common with terazosin
and doxazosin than with alfuzosin and tamsulosin (given at bed time for
terazocin, perazocin,alfuzacin) Or with meal to decrease absorption and
hypotensive side effect (tamusolin,solidosin)
• This adverse effect occurs in approximately 2% to 14% of treated patients and is most commonly associated with immediate-release
terazosin and doxazosin; is less commonly associated with extended release alfuzosin and extended-release doxazosin; and least
commonly associated with tamsulosin and silodosin.
2. Ejaculation disorders, including delayed, absent and retrograde ejaculation,
occur with all adrenergic antagonists. This is largely thought to be due to
pharmacologic blockade of peripheral α-adrenergic receptors at the bladder
neck or a decrease in seminal fluid production.
3. α1-Blockers, particularly tamsulosin, have been shown to increase the risk of
intraoperative floppy iris syndrome in cataract surgerya patient who needs
cataract surgery should have this ophthalmologic procedure performed first, if
possible. Although the drug will not need to be held or
discontinued, the ophthalmologist can plan to use certain surgical
techniques
4. Rhinitis and malaise: due to blockade of α-adrenergic receptors in the
vasculature of the nasal mucosa and in the central nervous system, self limiting,
Avoid use of topical or oral decongestants, as these may exacerbate obstructive
voiding symptoms.
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51. Drug interaction:
• Hypotensive adverse effects of terazosin and
doxazosin can be additive with those of
diuretics, antihypertensives, and
phosphodiesterase type 5 inhibitors (eg,
sildenafil).
2/25/2018 51

52. 5α-Reductase Inhibitor
Monotherapy
• 5α-Reductase inhibitors reduce the static factor, which
results in shrinkage of an enlarged prostate by approximately
20% to 25% after 6 months.
• Two subtypes of 5α-reductase, Type I and II, are present in
the prostate; the majority is the Type II isoenzyme.
• Finasteride is a selective Type II isoenzyme inhibitor,
whereas dutasteride is a nonselective inhibitor of both
Type I and Type II isoenzymes.
• When compared with finasteride, dutasteride produces a
faster and more complete inhibition of 5α-reductase in
prostate cells. However, no difference in clinical efficacy or
adverse effects has been demonstrated between these two
agents.
2/25/2018 52

53. • 5α-Reductase inhibitors have a delayed onset of
action (ie, peak effect may be delayed for up to 6
months) and are most effective in patients with
moderate LUTS and larger size prostate glands
(greater than 30 g).
• 5α-Reductase inhibitors reduce clinical
progression of BPH, specifically the risk of
developing acute urinary retention and the need
for surgical intervention.
• 5α-Reductase inhibitors work by causing
apoptosis of prostatic epithelial cells, leading to
a reduction in prostate volume by 18% to 28%
and serum PSA level by 50% after 6 to 12
months.
2/25/2018 53

54. 2/25/2018 54

55. • A minimum of 6 months is required to evaluate
the effectiveness of treatment.
• This is a disadvantage in patients with moderate
to severe symptoms, as it will take that long to
determine whether the drug is or is not effective.
• Unlike α-adrenergic antagonists, 5α-reductase
inhibitors are used to prevent BPH related
complications and disease progression.
Finasteride has been shown to reduce both the
incidence of acute urinary retention by 57% and
the need for prostate surgery by 55% in patients
with significantly enlarged prostate glands
(greater than 40 g)]
2/25/2018 55

56. Side Effects
Adverse effects include:
1. decreased libido
2. erectile dysfunction
3. ejaculation disorders (These side effects are
reversible).
4. gynecomastia and breast tenderness.
5. When used to prevent prostate cancer, these agents
reduce the incidence of prostate cancer by 25%, but are
suspected to increase the risk of developing moderate to
high grade cancer, if prostate cancer does develop.
6. Serum testosterone levels increase by 10% to 20% in
treated patients; however, the clinical significance of this
is not clear at this time.
2/25/2018 56

57. 1. Drug interactions are uncommon.
2. These drugs decrease serum levels of PSA by
approximately 50%. Therefore, to preserve the
usefulness of this laboratory test as a diagnostic
and monitoring tool, it is recommended that
prescribers obtain a baseline PSA prior to the
start of treatment and repeat it at least annually
during treatment.
2/25/2018 57

58. Combination Therapy
• combination of an α-adrenergic antagonist and
5α-reductase inhibitor may be considered in
symptomatic patients who do not respond to an
adequate trial of monotherapy or in those at high
risk of BPH complications, that is, those with an
enlarged prostate of at least 30g.
• more expensive and can cause more adverse
effects than single drug treatment.
2/25/2018 58

59. 5- phosphodiesterase inhibitor
• FDA approved only Tadalafil for LUTS
• Once daily dosing of tadalafil is approved for treatment of LUTS. It may be
prescribed alone or along with an α-adrenergic antagonist or 5α-
reductase inhibitor.
• This inhibits the proliferation and contraction of prostatic smooth
muscle, or enhances the action of nitric oxide.
• For those with BPH and erectile dysfunction, or those patients with LUTS
that is not responsive to α-adrenergic agonists.
• It decrease AUA score but it does not increase urinary flow rate or reduce
PVR
• The usual recommended dose is 5 mg by mouth daily; the dose should be
reduced to 2.5 mg daily if the creatinine clearance is 30 to 50 mL/min
• Common adverse effects include headache, dizziness, dyspepsia, back
pain, and myalgia
• Tadalafil is contraindicated in patients on nitrates by any route of
administration; patients with unstable angina, uncontrolled or high-risk
arrhythmias, persistent hypotension, poorly controlled hypertension, or
New York Heart Association Classification IV congestive heart failure; or
patients who have had a myocardial infarction within the past 2 weeks
2/25/2018 59

60. Antimuscarinic Medications
• For patients experience storage symptoms (nocturia,
frequency, urgency, urge incontinence)
• the addition of an anticholinergic agent (eg,
tolterodine) to an α-adrenergic antagonist with or
without a 5α-reductase inhibitor to inhibit irritative
symptoms (eg, urinary urgency and
frequency)mediated by M2 and M3 muscarinic
receptors should be cautious in patients at the
highest risk of anticholinergic agent-induced acute
urinary retention (those with a high postvoid
residual urine volume (250 mL or more). If
prescribed, it is good practice to monitor the
IPSS and PVR urine and warn patients about
the risks and symptoms of urinary retention.
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61. COMPLEMENTARY AND
ALTERNATIVE MEDICINE
2/25/2018 61

62. • Many types are available:
1. saw palmetto
2. stinging nettle
3. South African star grass
4. pumpkin seeds
5. bark of the African plum tree.
• However, the AUA does not recommend
any dietary supplement or other
nonconventional therapy for the
management of LUTS secondary to BPH.
2/25/2018 62

63. Surgery
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64. Transurethral resection of the prostate (TURP)
1. The gold standard for relieving BOO secondary to
BPH.
2. The removal of inner part of the prostate gland via
an endoscopic approach through the urethra.
3. Complications: urinary incontinence, urinary tract infection, bladder
neck stenosis, urethral stricture, retrograde ejaculation, and erectile
dysfunction
• A rare complication unique to TURP is the TURP syndrome, which is dilutional
hyponatremia resulting from absorption of the irrigant fluid (glycine) used
during surgery.
• Recent technologic advances have allowed saline to be used as the irrigation
fluid during TURP, and this has reduced the incidence of TURP syndrome.
2/25/2018 64

65. Open prostatectomy
• via a suprapubic incision, or retropubically
• Reserved for patients:
– with very large prostates (>75 g)
– patients with concomitant bladder stones or
bladder diverticula
– and patients who cannot be positioned for
transurethral surgery
2/25/2018 65

66. Minimally invasive treatment
• Transurethral incision of the prostate (TUIP) for
smaller prostates (<30 mL)
• Laser treatment - Used to cut or destroy prostate tissue
• Transurethral microwave therapy (TUMT) - Generates
heat that causes cell death in the prostate, leading to
prostatic contraction and volume reduction
• Transurethral needle ablation of the prostate (TUNA)
• High-intensity ultrasonographic energy therapy -
Currently in the clinical trial stage
• Prostatic stents - Flexible devices that expand when put
in place to improve the flow of urine past the prostate
• Laparoscopic prostatectomy
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67. THANK YOU
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