BPH
The most common disease of aging men
Present in majority of men Prevalence : 60yr : 50%↑
85yr : 90% Wide variance in symptoms Large prostate does not equal
voiding problems
LUTS Morbidity & Complication of BPH Mortality of BPH : Rare LUTS : Bothersome Highly variable Treatment :
Patient’s perceptionDegree of interfering life
style
Definitions and Terminology BPH : Stromal and epithelial
hyperplasia in periuretheral zone LUTS : Lower urinary tract symptoms The relationship of BPH & LUTS : Complex LUTS or LUTS suggestive of BPH >>
prostatism BPH : Bothersome LUTS by histological BPH
or increased tone of the prostate
LUTS Irritative versus Obstructive Irritative
Frequency/urgency/nocturia Obstructed
Slow stream/stranguria/start-stop Difficult to distinguish by history
alone since symptoms overlap
Medical History Surgery, general health Voiding History: polyuria,
stranguria, frequency, urgency post void dribbling
Voiding diary (nocturia) Urinary Infections :culture Incontinence
Physical Examination DRE Neurologic exam
Mental status Ambulatory status Neuromuscular function Anal sphincter tone
PSA Screening for cancer 10 year life expectancy and for
whom the presence of cancer would change management
One predictor of natural Hx of BPH
Optional Initial Test Urine Cytology : Bladder Ca, CIS
Predominantly irritative Sx Smoking or other risk factors
Serum Creatinine : Not recommended Renal insufficiency : 1%↓ Not more common than general
population Non BPH cause as diabetic
nephropathy
Symptom Assessment Sx alter QOL Sx quantification
Severity of disease Response of therapy Sx progression
0~7 : mild 8~19 : moderate 20~35 : severe
Not a replacement for personal discussion of Sx with the patient
Symptom Assessment IPSS : Recommended Other validated assessment : optional
Frequency and severity of LUTS Bother score Interference with daily activities Urinary incontinence Sexual function Health related – QOL
ICS Questionnaire, DPSS, BPH impact index, IPSS QOL, Sexual function Questionnaire
Optional Diagnostic Test Uroflometry measures rate of urine
flow Not a first line test
Post-void residual urine (PVR) useful tool for evaluation and treatment Non-prostatic case of Sx Selection of invasive Tx Prior failed BPH Tx Quantitative method to diagnose and
follow result of treatment
Qmax : rate of urine flow Predict the response to surgery Predict the natural Hx of BPHAdvantages LUTS with Normal Qmax : non prostatic
cause Qmax < 10ml/sec : obstructionDisadvantages Sx response is not dependent on Qmax Test / retest variability, lack of well
designed study→ Not feasible to establish cut-point
PVR Bladder dysfunction Identifies favorable response to Treatment Progression of disease Clinical tool not a singular diagnostic test Test / retest variability Lack of outcome studies No PVR cut-point
Optional Doesn’t predict the response to medical Tx Elevated PVR without UTI, renal insufficiency,
bothersome Sx - No level of RU mandates invasive Tx
Optional Diagnostic Tests Who Choose Invasive Tx Pr-flow study
Qmax > 10ml/sec & surgery considered Prior failed surgery Neurologic disease Not indicated to predict response to medical
Tx Cystoscopy : Hematuria, urethral stricture
r/o Bladder Ca, prior surgery TRUS : Size & shape, selection of surgery
CMG, IVP, USG of Kidney Not recommended Indicated in Hematuria, UTI Renal insufficiency, stone Hx,
upper tract surgery Hx
Initial Management and Discussion of Treatment Options
Watchful waiting Medical therapy – pills Minimally invasive surgery Surgery
Treatment Watchful waiting
Mild Symptoms Mod or severe Symptoms without Renal
insufficiency, UTI, retention Increase water intake↓ Decrease alcohol↓, Caffeine↓ SODA DRE, PSA : suggests natural Hx of
Sxflow rate, AUR, surgery
Medical Treatment Options
1. Alpha-adrenergic blockers2. 5 alpha-reductase inhibitors3. Combination therapies4. Phytotherapy
Alpha-adrenergic Blockers
Opens prostatic urethra by relaxing smooth muscle in prostate
Doxazosin, terazosin, flomax, uroxatrol and rapaflo
Equal effectiveness Differences in adverse events LUTS secondary to BPH Very effective in relieving symptoms
of BPH
Alpha-adrenergic Blockers Side Effects: postural hypotension,
retrograde ejaculation Hypertension and cardiac risk
factors LUTS – Alpha blocker only: incidence of CHF
Patients with hypertension : separate management of hypertension
May make cataract surgery difficult (floppy iris syndrome)
5 Alpha-reductase Inhibitors Reduces prostate volume 25-28% Reducing volume doesn’t always
relieve obstruction Symptomatic prostatic enlargement
treatment helps to prevent progression of disease (AUR, surgery)
Sexual dysfunction, long-term Tx Not appropriate for men with LUTS
without prostatic enlargement
Natural History of BPH
PLESS study 1. 3,040 clinical BPH patients2. IPSS: moderate to severe3. Qmax: <15 ml/s4. DRE: enlarged prostate gland5. PSA <10 ng/ml (PSA 4-9.9: negative biopsy)6. Follow-up: 4 years
Surgery Minimally Invasive (office)
Microwave TUNA Interstitial Laser
Surgery (operating room) TURP HOLAP HOLEP
Surgery Patient selection determines type of
procedure offered Surgery very effective in properly
selected patients Majority of patients stop medications Absolute indications
Retention Recurrent infections Bleeding Stones
Surgery Absolute Indications
Retention Repeated infection Bladder stones
Relative indications Worsening symptoms Rising urine retention Desire to stop medication
Surgery Minimally invasive surgery
Better symptom results than medication Minimal recovery – days Low incidence of long-term side effects No incontinence after treatment Higher future retreatment rates than
surgery Not effective for patients in urine
retention Excellent alternative to medication
Surgery OR based surgery
Most effective means of relieving prostate obstruction
Requires general/spinal anesthesia Removal of prostate tissue Variety of energies used to remove
tissue Requires catheters after treatment Usually involves hospitalization
Surgery Indicated for urine retention Highest side effects
Possible incontinence Retrograde ejaculation
Best treatment outcomes Improves flow rate Lowers voiding symptoms