A 75-year-old man is experiencing urinary symptoms of nocturia, frequency, incomplete emptying, and straining. He has a history of recurrent urinary tract infections, a large bladder diverticulum, and pronounced prostatic enlargement. His symptoms have only modestly improved with medical treatment. The best approach is to refer him to a urologist for consideration of an open surgical procedure to address his prostate and bladder issues.

1. BENIGN PROSTATIC
HYPERPLASIA (Module 2
of Renal/Prostate Disease)
Bill Lyons, M.D.
UNMC Geriatrics & Gerontology

2. BPH: LEARNING OBJECTIVES
 Pathophysiology and
Epidemiology
 Workup
 Differential Diagnosis
 Medical Treatment
 Surgical Treatment

3. BACKGROUND
 Incidence age-related
 Autopsy studies, BPH prevalence:
 20% men in their 40s
 90% men over 80
 Two ingredients for BPH
 Androgens (dihydrotestosterone): castration
shrinks established BPH, improves symptoms
 Aging (aging prostate more androgen-
sensitive)

4. BACKGROUND, cont.
 Prostate: stromal
+epithelial tissues
 BPH from either alone
or in combination
 Stroma has abundant
adrenergic innervation
 Increased tone 
increased resistance to
urine flow through
prostatic urethra

5. BPH: PATIENT HISTORY
 Symptoms: Obstructive & Irritative
 Obstructive
 Increased resistance to flow
 Neck of bladder, prostatic urethra
 Static and dynamic components
 Irritative
 From bladder’s response to flow resistance
 Hypertrophy + collagen deposition
 Detrusor instability, less passive compliance

6. OBSTRUCTIVE VOIDING
SYMPTOMS
 Hesitancy
 Reduced force of stream
 Sense of incomplete emptying
 Intermittent flow
 Strain to urinate
 Post-void dribbling

7. IRRITATIVE VOIDING SYMPTOMS
 Urgency
 Frequency
 Nocturia

8. AUA QUESTIONNAIRE
 Seven questions, each 0-5, total 0-35
 Evaluate before start therapy, and to assess results
of therapy. Over the last month:
 1 Incomplete Emptying?
 2 Frequency – go again less than 2 hr later?
 3 Intermittency stop/start several times?
 4 Urgency – difficult to postpone urinating?
 5 Weak Stream?
 6 Straining – push/strain to begin?
 7 Nocturia – how many times on typical night?

9. DIFFERENTIAL DIAGNOSIS
 Prostate cancer
 Bladder cancer
 Bladder stone
 UTI (also BPH complication)
 Urethral stricture (trauma, instrumentation,
urethritis)
 Contracture of bladder neck (instrumentation)
 Neurogenic bladder (CVA, MS, trauma, DM)

10. PHYSICAL EXAMINATION
 DRE – size,
consistency, tenderness
 Size of gland correlates
poorly with symptoms

11. PHYSICAL EXAM, cont.
 Abdomen – palpation, percussion
 Enlarged bladder?
 Normal = well below umbilicus
 Neurological
 Perineal sensation
 Sphincter tone
 Anal wink
 Bulbocavernosus reflex

12. ADDITIONAL STUDIES
 Urinalysis and urine culture
 Serum creatinine
 PSA controversial (BPH, cancer overlap)
 Upper tract imaging for hematuria, renal
insufficiency
 Post-void residual
 Urodynamic studies
 Suspected neurologic disease
 Failed surgery

13. MEDICAL TREATMENT
 Alpha blockers perhaps better if significant
component of stromal smooth muscle
 5-alpha-reductase inhibitors for BPH from
primarily excess epithelial tissue

14. MEDICAL TREATMENT, cont.
 Cannot predict
response to a particular
therapy

15. MEDICAL TREATMENT, cont.
 Mild BPH: watchful waiting
 Prostate and bladder neck contraction
mediated via alpha-1a receptors
 Alpha Blockers:
 Alpha-1: prazosin, terazosin, doxazosin
 Alpha-1a: tamsulosin

16. MEDICAL TREATMENT, cont.
 Alpha Blockers, cont.
 Dosed daily: terazosin, doxazosin, tamsulosin
 Dosed bid: prazosin
 Slow dose escalation required (perhaps less
so with tamsulosin)
 Side Effects: orthostatic hypotension and
dizziness, headache, rhinitis and nasal
congestion, retrograde ejaculation, fatigue

17. MEDICAL TREATMENT, cont.
 5-alpha-reductase inhibitor: finasteride
 Blocks conversion of testosterone  DHT
 Reduces epithelial component of prostate,
shrinks gland, decreases PSA
 Months (>6) of treatment before improvement
 Symptoms better only if large prostate?
 Side Effects: reduced libido, erectile
dysfunction

18. MEDICAL TREATMENT, cont.
 Combine alpha blockade and finasteride?
 RCT over 3000 men (McConnell et al, NEJM
2003)
 Mean age 63, mean f/u 4.5 years
 Doxazosin vs. finasteride vs. combo vs.
placebo
 Clinical progression: combo > either drug >
placebo

19. MEDICAL TREATMENT, cont.
 Combination Therapy, continued
 Placebo-controlled Prostate Cancer
Prevention Trial:
 Finasteride reduced overall prevalence of
prostate cancer
 But increased proportion of poorly-differentiated
cases
 Experts debating whether true harm

20. MEDICAL TREATMENT, cont.
 Consider adding
finasteride
 Men with large
prostate
 Progressing
symptoms
 Discuss risk

21. SURGERY
 Who to refer for
interventions?

22. SURGERY, cont.
 Consider for referral:
 Refractory retention
 Failed attempt at d/c of catheter
 Overflow incontinence
 Large bladder diverticula
 Recurrent UTI
 Recurrent/persistent gross hematuria
 Bladder stones
 Renal insufficiency

23. SURGERY, cont.
 Transurethral Resection of the Prostate
 Spinal anesthesia
 1-2 day hospital stay
 Better symptom scores than minimally-
invasive methods
 Risks: ED, incontinence, retrograde
ejaculation, urethral stricture/bladder neck
contracture
 Urgency/frequency may persist

24. SURGERY, cont.
 Transurethral Incision of the Prostate
 Faster, less morbid than TURP
 Requires right prostate anatomy (small gland)
 Higher rate of reoperation vs. TURP
 But less incidence of stricture, incontinence,
retrograde ejaculation

25. SURGERY, cont.
 Open Prostatectomy
 When gland too large to treat otherwise
 Bladder stones, diverticula
 Minimally Invasive Procedures
 Laser, needle ablation, electrovaporization,
hyperthermia, ultrasound
 Need RCT, long-term follow-up
 Intraurethral stents
 Patients with short life expectancy, high risk

26. REFERENCES AND READINGS
 Lieber MM. Mayo Clin Proc 1998;73:590-
596.
 McConnell JD et al. NEJM 2003;349:2387-
2398.
 Stoller ML, Carroll PR. Urology. Chapter 23
in: Tierney LM Jr, McPhee SJ, Papadakis
MA, Current Medical Diagnosis & Treatment,
2004, McGraw-Hill.
 Thompson IM et al. NEJM 2003;349:215-
224.

27. Post-test 1
You assume the care of a 75-year-old man who was recently
discharged from the hospital, where he had undergone
treatment for diverticulitis. In reviewing his hospital discharge
summary, you find that an abdominal and pelvic CT was
performed, showing sigmoid diverticulitis, a simple right renal
cyst, a large urinary bladder diverticulum, and pronounced
prostatomegaly. Clinically, his diverticulitis has resolved, but he
complains of chronic nocturia, urinary frequency, sense of
incomplete emptying, and straining to initiate his urinary stream.
Symptoms are modestly improved on a regimen of terazosin 5
mg qhs and finasteride 5 mg qd. Other past medical history
includes knee osteoarthritis, diet-controlled diabetes mellitus,
recurrent urinary tract infections, and depression.
The best approach to treating this man’s urinary complaints is
to:

28. The best approach to treating this
man’s urinary complaints is to:
(a) Check his PSA, and consider referral for
prostate biopsy, depending on the result.
(b) Increase the dose of his terazosin.
(c) Refer him to a urologist for consideration of
TURP.
(d) Refer him to a urologist for consideration of
an open procedure.
(e) Prescribe a bladder relaxant, such as
oxybutynin.

29. Correct Answer: (d) Refer him to a
urologist for consideration of an open
procedure.
Feedback:(d)
This patient’s recurrent urinary tract infections and bladder
diverticulum suggest that he is more appropriately managed by
surgical intervention than by medications alone. The presence
of the large diverticulum makes it likely that he will need an open
procedure prostatectomy and diverticulectomy/bladder repair.
Checking his PSA is not likely to be helpful, as a high PSA is
nonspecific and may represent BPH, prostate cancer, or urinary
tract infection. Increasing the dose of terazosin might be the
right choice, if not for the recurrent UTIs and bladder
diverticulum. TURP may help with the obstructive symptoms, but
won’t solve the diverticulum problem. And prescribing a bladder
relaxant would likely make matters worse by increasing the risk
of urinary retention.