Benign Prostate Hypertrophy

(BPH)
 Introduction
Benign prostatic hyperplasia refers to nonmalignant growth
of prostate.
age-related phenomenon in nearly all men, starting at approx 40
years of age.
Histologically
10% of men in their 30s
20% in 40s
50-60% in 60s
80-90% in their 70s and 80s.
Prostate size increases from
25g to 30g for men in 40s
30g to 40g in 50s
35g to 45g in 60s.
 Introduction
However, many men with histological BPH
may never develop symptoms, which is when
treatment is sought.
Etiology
poorly understood despite decades of intense
research
hyperplasia thought to be stimulated by
dihydrotestosterone (DHT)
Additional risk factors: positive family history
 Symptoms
Lower urinary tract symptoms (non-specific, can also
include those with prostatitis, prostate cancer, bladder
outlet obstruction like urethral stricture, stones, etc.)
Hesitancy, frequency, urgency, straining, weak flow,
prolonged voiding, partial or complete urinary
retention, small voided volumes, nocturia, painful
urination.
If peak urinary flow rate <10 mL/s, then subvesical
obstruction seen in 90% patients
Risk factors: changes to bladder anatomy and function,
UTI, formation of bladder stones, renal failure
 Diagnosis
Careful history and physical examination
including DRE
DRE notoriously unreliable in assessing size, in
fact, shown to underestimate size of prostate
Still important because some men found to have
prostate cancer based on DRE
UA, serum Cr. PSA depending on patients life
expectancy and circumstances.
PSA is an individualized decision to be made with
patient and physician
 Diagnosis
Further evaluate with AUA Symptom Score, or International
Prostate Symptom Score (IPSS)7 questions each on
severity scale of 0-5: frequency, nocturia, weak urinary
stream, hesitancy, intermittence, incomplete emptying, and
urgency.
If score <8, mildly symptomatic and recommend yearly
reevaluation
If 8-35, may consider additional tests if history confounded
by neurological diseases, prior failed BPH therapy, and
those considering surgery.
Optional tests:
Urinary flow rate <10 mL/s highly suggestive of outlet
obstruction
Postvoid residual urine measurement with transabdominal
ultrasound or in-and-out catheterization.
 Management

If no obstruction and limited discomfort, do

not need to treat!!
Non-pharmacological Management
Non-pharmacological Management
Mild symptoms or limited discomfort?
o Watchful waiting and annual evaluation
o Lifestyle Modifications
Avoid fluids prior to bedtime or going out
Reduce caffeine and alcohol
Scheduled urination at least once every 3
hours.
Double voiding: after urinating, wait and try
to urinate again.
 Pharmacological Treatment
Alpha-1-adrenergic antagonists
Relax smooth muscle in the bladder neck, prostate capsule, and
prostatic urethra
Immediate relief!
Examples
Terazosin, Doxazosin
Initiate at bedtime (hypotension)
Tamsulosin, Alfuzosin
Lower potential to cause hypotension, syncope
Minor differences in the adverse events profiles, equal clinical
effectiveness
Major Side Effects
HYPOTENSION!
Ejaculatory Dysfunction (particularly Tamsulosin)
Interaction with phosphodiesterase-5 inhibitors
Potentiated effects of hypotension
Separate doses by at least 4 hours
 Pharmacological Treatment
5-alpha-reductase inhibitors
Reduces the size of the prostate gland
Prevents conversion testosteronedihydrotestosterone (DHT)
~ 6 to 12 months before prostate size is sufficiently reduced to
improve symptoms!!
Indefinite treatment, as discontinuation may lead to symptom
relapse.
Examples
Finasteride (initiated and maintained at 5 mg once daily)
Dutasteride
Side Effects
Sexual dysfunction
Decrease PSA
Take into account during interpretation
 Pharmacological Treatment
Anticholinergics
monotherapy for patients with predominately
irritated symptoms related to overactive bladder
Frequency, urgency, incontinence
Examples
Oxybutynin, Tolterodine
Side Effects
Extensive!
Dry mouth, blurred vision, tachycardia, constipation etc
 Pharmacological Treatment
Combination therapy
Severe symptoms without maximal response to
maximal monotherapy
Alpha 1 and anticholinergics
Alpha 1 and reductase inhibitors
 If still fails?
If all else fails: Surgery or Minimally Invasive
Surgical Therapies
Many surgical/interventional options
MIST
Transurethral needle ablation (TUNA), transurethral
microwave therapy (TUMT), Transurethral
Electroevaporation of The Prostate TUVP
Surgery
Open Prostatectomy
Endoscope
Transurethral Incision of the Prostatce (TURP)
 Management
When to get Urology involved?
Bladder Obstruction syndrome
Men <45 years old
Presence of hematuria in the absence of infection
Abnormality on prostate exam (nodule,
induration, or asymmetry)
Men with incontinence
Severe symptoms
 References
Roehrborn CG. Benign prostatic hyperplasia:
an overview. Rev Urol. 2005;7 Suppl 9:S3-S14.
McVary KT, Roehrborn CG, Avins AL, et al.
Update on AUA guideline on the management
of benign prostatic hyperplasia. J Urol. 2011
May;185(5):1793-803. doi:
10.1016/j.juro.2011.01.074. Epub 2011 Mar
21.