A 64-year-old man experiences poor urinary flow and nocturnal urination, with symptoms indicating potential benign prostatic hyperplasia (BPH), prostatitis, or prostate cancer. Diagnosis involves various investigations including digital rectal examination and ultrasound, while management may include watchful waiting, pharmacotherapy with α1-blockers or 5α-reductase inhibitors, and surgical options if necessary. Recommendations for managing lower urinary tract symptoms include lifestyle adjustments and bladder training.

1. PROSTATE DISEASE
CASE DISCUSSION SESSION-5
Dr. S P Srinivas Nayak
Assistant Professor
Dept. of Pharmacy Practice
Parul University

2. CASE.1
A 64-year-old man presents with complaints of poor urinary flow and
having to visit the toilet at least twice during the night to pass urine.
There is no family history of DM, HTN & Prostate disease and he is
taking no medication., Patient has no symptoms of pedal edema., RBS
found was in Normal range, BP: 130/80 mm/Hg
On questioning, he also describes symptoms of urinary frequency,
urgency and urge incontinence, but fever is absent.
Question:
What investigations are appropriate to diagnose the case and how
should he be managed?

3. PROSTATE DISEASE
1. Benign prostatic hyperplasia
2. Prostatitis
3. Prostate cancer

4. BENIGN PROSTATIC
HYPERPLASIA (BPH)
most common, presence of BPH in 50% of males aged 51–60
years
The prostate gland:
The prostate is a part glandular, part fibromuscular structure about
the size of a walnut that surrounds the first part of the male
urethra at the base of the bladder

7. Prostatic hypertrophy is directly related to the ageing process and to
hormone activity.
The primary androgen responsible for the development and progression
of BPH is DHT
We have two isoenzymes 5α-reductase:
type 1 is found in most 5α-reductase producing tissues such as the liver,
skin and hair.
type 2 is predominant in genital tissue, including the prostate

9. As the prostate enlarges, it can compress the urethra and this,
can lead to bladder outflow obstruction (BOO) and lower
urinary tract symptoms (LUTSs).
Therefore, the term BPH includes benign prostatic enlargement
(BPE), the clinical features associated with urinary obstruction
and LUTSs.

10. SYMPTOMS
Men with BPH can develop bothersome LUTSs
LUTSs can be divided into 2 symptoms
1. symptoms of failure of urine storage (irritative) and
2. those caused by failure to empty the bladder (obstructive or
voiding).

11. LUTSS
Irritative symptoms:
• Frequency
• Nocturia
• Urgency and urge
incontinence.
Obstructive symptoms:
• Poor urinary flow
• Hesitancy in initiation of micturition
• Post-micturition dribble
• Sensation of incomplete emptying
• Occasional acute retention of urine
requiring emergency treatment

13. EXAMINATION AND INVESTIGATIONS
Physical examination:
1. a digital rectal examination (DRE)
examiner palpating the prostate with
a finger through the rectum wall.
2. transrectal ultrasonography (TRUS)

14. Post void residual (PVR) volume:
Normal is 50ml.
ultrasound scan, Prostatic ultrasound
Transrectal ultrasonography(TRUS)
Cystoscopy
Urinalysis
prostate-specific antigen (PSA)
urine cultures if infection

15. TREATMENT
1. Watchful waiting
2. Pharmacotherapy
3. surgical treatments:
A. Transurethral resection of the prostate (TURP)
B. Open prostatectomy.
C. transurethral microwave heat treatment (TUMT),

16. ADVICE IN MODERATE CONDITION
Advice for the management of lower urinary tract symptoms Limit
fluid consumption before going out and before going to bed (to
reduce urinary frequency and nocturia)
Reduce alcohol and caffeine intake Schedule toilet visits Manage
constipation
Review medication (including diuretics and other medicines that can
affect the urinary system)
Bladder training (encourage patient to go longer between voiding and
increase the volume voided)
Use distraction techniques (practice breathing exercises and penile
squeezing to control symptoms of irritation)

17. PHARMACOTHERAPY
three subtypes of α1 receptors exist (α1A, α1B and α1D). The
α1A is thought to be the dominant receptor in the prostate

18. PRAZOSIN
Prazosin was the first α1 -blocker used to relieve the symptoms
of BPH but it lacks relative selectivity for α1A receptors and has
been associated with many adverse affects such as drowsiness,
weakness, headache and postural hypotension (especially after
the first dose).

19. TERAZOSIN.
Terazosin is long acting α1 -blockers in the management of BPH.
Efficacy is dose dependant and dose titration is necessary, as
terazosin can cause postural hypotension. Adverse effects,
although generally mild, occur more frequently than with other α1
-adrenoceptor antagonists.

20. INDORAMIN
Indoramin is readily absorbed from the gastro-intestinal tract and
undergoes extensive first-pass hepatic metabolism.
Not commonly used

21. DOXAZOSIN.
Doxazosin has a long half-life of about 22h, which allows for
once-daily dosing. When starting treatment, dose titration is
recommended to limit postural hypotension.

22. TAMSULOSIN
Tamsulosin is a selective inhibitor of the α1A and α1B-
adrenoceptor. It has an elimination half-life of about 13h and
is available as a prolonged release formulation that allows
once-daily dosing, well tolerated.
Intraoperative floppy iris syndrome (IFIS) in cataract surgery,
stopped 1-2 weeks before surgery

23. ALFUZOSIN.
Alfuzosin displays a higher selectivity for the prostate compared
with tamsulosin or doxazosin. It has a half-life of 5h, but it is
available as a once-daily formulation. It has a rapid onset of action
and good tolerability

24. 5Α-REDUCTASE
INHIBITORS
The primary androgen responsible for the development and
progression of BPH is DHT
finasteride and dutasteride are two agents currently available

25. FINASTERIDE
Finasteride is a type 2, 5α-reductase inhibitor that can reduce
prostate size by about 30%,.
Side effects include: decreased libido, impotence, reduced
ejaculatory volume and, less commonly, gynaecomastia and
breast tenderness.
Serum PSA may be reduced by 50% in the first year of
treatment with finasteride.

26. DUTASTERIDE
Dutasteride inhibits both type 1 and type 2 isoenzymes of 5α-
reductase.
this double inhibition can reduce serum dihydotestosterone levels by
about 90%.
Dutasteride decreases prostate volume by up to 26% and reduces
the risk of progression to serious complications of BPH.
LUTSs also improve after 6 months of treatment.
Dutasteride is well tolerated although side effects which include
erectile and ejacuatory dysfunction and breast enlargement occur
with similar frequency to finasteride.

27. COMBINATION THERAPY

28. THANK YOU