Benign Prostatic Hyperplasia and Lower Urinary Tract Symptoms

1. BPH AND LUTS
Salman Bangash 2014-081

2. BPH-LUTS
• Benign prostatic hyperplasia is the histological pattern of the
prostate, characterized by proliferation of smooth muscle
and epithelial cells within the prostatic transition zone. This
may lead to prostatic enlargement.
• Lower urinary tract symptoms refer to storage and/or voiding
disturbances.
• BPH-LUTS refers to bothersome lower urinary tract symptoms
linked to the prostate.
• Not all men with BPH have LUTS and not all patients with LUTS
have BPH.

3. BPH
• It is considered a normal part of aging in men and is
hormonally dependent on testosterone and DHT
production.
• 50% of men develop BPH by age 60 years and 90% by
age 85 years.

4. BPH
• Patients with mild LUTS can be treated medically.
• TURP ( transurethral resection of the prostate ) is the
standard procedure for relieving bladder outlet
obstruction secondary to BPH.

5. PROSTATE
• It is a walnut sized gland and is a part of the male
reproductive system
• Located anterior to the rectum and distal to the urinary
bladder.
• It is connected directly with the penile urethra hence
it’s a conduit between the bladder and urethra.
• BPH originates in the Transition zone which surround the
urethra.

6. PROSTATE

7. PROSTATE
• Main function of the prostate is to secrete and alkaline
fluid that compromises 70% of the seminal volume.
• Secretions produce lubrication and nutrition for the
sperm.
• Alkaline fluid helps neutralize the acidic vaginal
environment.

8. RISK FACTORS
• Obesity
• Lack of physical activity
• Erectile dysfunction
• Increasing age
• Family history of BPH

9. EVALUATION OF PATIENTS
• Medical history
• Directed physical exam
• Urinalysis
• PSA testing
• Symptom assessment

10. MEDICAL HISTORY
• Nature and duration of symptoms
• Fluid intake – amount and types of fluid
• Sexual history
• Comorbid conditions
• Prior and current illness
• Prior surgery and trauma
• Current medications
• Any previous treatments.

11. CLINICAL
MANIFESTATIONS
• Urinary frequency
• Urgency
• Nocturia
• Hesitancy
• Incomplete emptying of bladder
• Straining
• Dribbling

12. SEXUAL HISTORY
• Sexual history is important because studies have
identified LUTS as an independent risk factor for erectile
dysfunction and ejaculatory dysfunction.

13. EXAMINATION
• DIGITAL RECTAL EXAM
--- Evaluate prostate for size, consistency, shape
and abnormalities suggestive of prostate
cancer (such as nodules or asymmetry)
• Assess suprapubic area to rule out bladder
distention
• Evaluate overall motor and sensory function of the
perineum and lower limbs

14. COMPLICATIONS
• Urinary retention
• Renal insufficiency
• Recurrent UTI
• Gross hematuria
• Bladder calculi
• Renal failure or Uremia

15. URINALYSIS
•Dipstick urinalysis should be performed in all BPH-LUTS
patients to rule out other diagnoses that may cause LUTS.
•Abnormal/borderline urinalysis results should be
repeated and/or followed with a urine culture

16. URINALYISIS
Urinalysis result Possible diagnosis
Hematuria
Kidney stones
Bladder cancer
Pyuria or nitrates
UTI
Urethral stricture
Proteinuria Underlying renal disease
Glucosuria diabetes

17. PSA TESTING
• BPH does not cause prostate cancer, however men at
risk of BPH are also at risk of developing prostate
cancer.
• It is a sensitive screening test for prostate volume.
• Men at age 50 who are expected to live at least 10
more year.
• 45 years in men who are at high risk ( African
American’s or close relative with prostate cancer )

18. ULTRASONOGRAPHY
• Help determine prostate and bladder size and degree
of hydronephrosis in patients with urinary retention.
• Transrectal ultrasonography is recommended in
selected patients to determine the dimensions and
volume of the prostrate.

19. CYSTOSCOPY
• It is indicated in patients whom a malignancy or foreign
body is suspected.

20. INTERNATIONAL PROSTATE
SYMPTOM SCORE
1-7 = mild 8-19 = moderate 20-35 = severe

21. AMERICAN UROLOGICAL
ASSOCIATION

22. TREATMENT FLOW CHART

23. MEDICAL THERAPY
• Alpha-blockers are a first-line option for men with
symptomatic bother who desire treatment
• 5ARI’s are an effective option for symptomatic patients
with demonstrable prostatic enlargement
• Combination alpha-blocker and 5-ARI therapy improves
symptom score and peak urinary flow vs. monotherapy;
appropriate for patients with LUTS associated with
prostatic enlargement
• A PDE5 inhibitor can be used once-daily in men with
moderate to severe symptoms and bother, to effectively
reduce symptoms of BPH-LUTS while maintaining sexual
function
• Phytotherapy is not recommended by the CUA

24. ALPHA BLOCKERS
• Selective antagonist of α1-adrenoceptors located in:
• Prostate
• Prostatic capsule
• Bladder base
• Bladder neck
• Prostatic urethra
• Help relax smooth muscle in the bladder neck and prostate;
allow urine to flow more freely
• Selective and non-selective alpha-blockers exist
• Non-selective alpha-blockers are not commonly used for BPH-
LUTS

25. ALPHA BLOCKERS
• First line options include
• Equal clinical effectiveness for LUTS secondary
to BPH
• Do not alter the natural progression of the
disease
• Choice of agent should depend on
comorbidities, side effect profile and tolerance
Selective :- Alfuzosin
Tamsulosin
Silodosin
Non selective: Doxazosin
Terazosin

26. SIDE EFFECTS
• Retrograde ejaculation
• Erectile dysfunction
• Asthenia •
• Dizziness
• Orthostatic hypotension
• Nasal congestion

27. 5-ALPHA REDUCTASE
INHIBITORS
• Indicated as first-line therapy for men with enlarged
prostates:
• Finasterideinhibits 5α-reductase Type 2 (prostate)
• Dutasterideinhibits 5α-reductase Type 1 AND 2 (liver, skin
and prostate)
• Blocks the conversion of testosterone to DHT (responsible for
prostate growth)
• Treatment with 5-ARIs reduce:
• Prostate size
• PSA
• Long-term risk of acute urinary retention
• Need for surgery

28. SIDE EFFECTS
• Reduced libido
• Erectile dysfunction
• Decreased ejaculate volume
• Breast tenderness

29. COMBINATION THERAPY
• Combined alpha-blocker and 5-ARI therapy is effective
for LUTS associated with prostatic enlargement
• Improves symptom score and peak urinary flow greater
than either monotherapy option
• Delays symptomatic disease progression
• Decreased risk of urinary retention and/or prostate
surgery

30. PDE5 INHIBITORS
• Promote smooth muscle relaxation.
• Improve LUTS.
• Improves quality of life.
• Effective in men with or without erectile dysfunction.
• Tadalafil is the only approved PDE5 inhibitor for BPH-
LUTS.

31. SIDE EFFECTS
• Headache
• Facial flushing
• Dyspepsia

32. TREATMENT RESPONSE
Drug class Time for symptom improvement
Alpha blockers 2-4 weeks
5 alpha reductase inhibitors Atleast 6 months
PDE5 inhibitors 4 weeks

33. CASE SCENARIOS
Case description Recommendation
Moderate – severe bother (PSA
1.3ng/ml)
Alpha blocker
Diabetes Alpha blocker
hypertension Alpha blocker
Erectile dysfunction Alpha blocker or PDE5
Enlarged prostate + PSA >
1.5ng/ml
5-ARI
Enlarged prostate + PSA >
1.5ng/ml + ED
5-ARI and/or PDE5
Bothersome sexual side effects
with α-blocker or 5-ARI PDE5

34. SURGICAL TREATMENT
• Renal insufficiency
• LUTS complications
• Patient requests surgical treatment
• Medication is ineffective
• Medication side effects are intolerable

35. PROSTATE SIZE
Very large ( 80-100g ) Large ( 30-80g ) Small ( <30g )
Open prostatectomy TURP TURP
Laser prostatectomy
-holium
-greenlight
Laser prostatectomy
-holium
-greenlight
Minimally Invasive
- TUMT
- TUNA

36. RISKS OF SURGERY
• Excessive bleeding requiring blood transfusion
• TUR syndrome
• Permanent sexual side effects:
• Retrograde ejaculation
• Erectile dysfunction (less common)
• Urinary tract infections
• Urinary incontinence
• Need for retreatment:
• Prostate regrowth
• Bladder/urethral strictures