1. BENIGN PROSTATIC HYPERPLASIA Brian Kim, PGY3

2. A Case…  Mr. X is a 58y/o AAM presents to your clinic complaining of hesitancy, frequency, and nocturia 3-4 times per night, which has been steadily worsening over the past few years. His urinary stream is weaker than it was a few years ago. He is not sure if he empties his bladder completely, but he denies a history of UTIs, dysuria, or any pain. He is otherwise well with no PMH or PSH. He in not taking any meds and has no allergies. On reviewing his family history, you find that his father and older brother died of prostate cancer in their fifties. General physical exam is normal. There is no inguinal adenopathy, nor lesions or masses. Rectal exam reveals prostate #3

3. Objectives  Introduction  Epidemiology  Pathogenesis  Course of BPH  Symptoms  Diagnostic Approach – exam, tools, etc  Treatment

5. Introduction  BPH is a very common problem among older men, often causing uncomfortable lower urinary tract symptoms  However, it rarely is a cause of mortality, with mortality rate in the 1980’s from 0.5-1.5/100,000

6. Epidemiology  The average prostate weights between 20-30 grams in normal 20-30 year old men.  The weight does not change much throughout the lifetime, unless the patient develops BPH.  Race has some influence on the risk for BPH. The relative risk for blacks and whites are similar, Asians were found to be of lower risk. Black men are more likely than white men to have larger prostate volume and more moderate to severe LUTS

7. Epidemiology cont…  In the Massachusetts Male Aging Study, increased risk of BPH was associated with Heart Disease, use of beta-blockers, and higher free psA levels  There is a weak inverse relationship between BPH and cirrhosis  Alcoholism may reduce the risk of BPH by way of reducing androgen levels

8. Pathogenesis  It is incompletely understood  Older age and Leydig cells of the testes are thought to be of most importance for the development of BPH.  Testosterone and Dihydrotestosterone are necessary but not sufficient to cause BPH.  Possible dysregulation of stromal growth factors… the stroma might have intrinsic properties that enable it to proliferate and to induce hyperplasia of the epithelium.  Decreased Cell Death: The avg life span of stromal cells is greater than 30yrs, where that of epithelial cells is about 2 yrs. This may be a major contributor to prostatic hyperplasia and enlargement.  Heritability is a more important determinant of LUTS than age, total prostate volume, or transition zone volume

9. Natural History of BPH  Symptoms do not necessarily have to be progressive, but most men have progressive disease which eventually requires treatment.  Peak flow rates on avg decrease about 2.1%/yr  Prostate volume on avg increases about 1.6%/yr  In 30-yr prospective study of 1057 men in 1991, 527 were given diagnosis of BPH and 110 underwent prostatectomy  Unsure if BPH is a risk factor for prostate CA, as both diseases are common in older men and because BPH increases likelihood of pt screened for prostate CA

10. Common Symptoms  Frequency of urination  Nocturia  Hesitancy  Urgency  Weak Urinary Stream  Postvoid Dribbling

11. Diagnostic Approach  A thorough history and physical exam with lab tests are essential in excluding disorders with similar symptoms and diagnosing BPH  Some of these disorders are UTI/Prostatitis, Prostate CA, Bladder CA, Bladder Calculi, and Neurogenic Bladder, and Urethral Stricture

15. AUA Symptom Score

16. AUA Symptom Score cont…  The Score is used to assess the severity of the symptoms of BPH.  Symptoms are classified as mild (score: 0-7), moderate (8-19), and severe (20-35)  Useful to assess symptoms over time in a qualitative way

17. IPSS

18. IPSS cont…  Uses the same scale as the AUA, but adds a QOL question: “If you were to spend the rest of your life with your urinary condition as it is now, how would you feel about it?”

19. Physical Exam  DRE must be done to assess the size, consistency, and for any induration, nodules, and symmetry/asymmetry (of lateral lobes). The rectal sphincter tone should be determined.

20. Labs  UA should be done to detect for blood/infection  Optional but supplemental tests include PSA, post- void residual volume, and max flow rate, BMP

21. Treatment  In general, BPH requires therapy only if symptoms affect QOL  Many men experience stabilization of symptoms over time  AUA and IPSS helpful in deciding to treat

22. Alpha-1-adrenergic antagonists  Generally considered first-line treatment  Include Terazosin, Doxazosin, Tamsulosin, Alfuzosin, Silodosin  Mechanism: Act by relaxing smooth muscle in the bladder neck, prostate capsule, and prostatic urethra  Alpha-1 receptors are abundant in prostate and base of bladder, and sparse in the body of the bladder  Important side effects are orthostatic hypotension, dizziness, and decreased ejaculate volume, retrograde ejaculation, and intraoperative floppy iris syndrome

23. 5-Alpha-Reductase Inhibitors  Include Finasteride and Dutasteride  Mechanism: Act by reducing the size of the prostate gland. Treatment for 6-12 months generally needed to see improvement in symptoms  Important side effects are decreased libido and ejaculatory/erectile dysfunction  Finasteride may reduce the overall risk of developing Prostate CA, but increase the risk of developing high- grade Prostate CA  Serum PSA decreases by about 50%, a change that must be kept in mind when interpreting results of PSA values

24. Other therapies…  Antimuscarinics  TURP  Common procedure for BPH  Indications: Failure of medical therapy, recurrent infections, patient preference  Advantages: decreased AUA symptom scores, increased urinary flow rates, decreased post-void residual volumes  Disadvantages: Possible urinary incontinence, urethral stenosis, need to repeat surgery

25. Interactive portion  Please break off into three groups  Reviewing the technique of a proper prostate exam  A chance to palpate Mr. X’s prostate (#3) from the initial case, as well as the prostates of 5 of his friends  Review case questions in small-group if time permits  Reconvene to discuss findings

26. In Summary…  BPH, while usually not a life-threatening disease, can significantly affect a patient’s QOL  Often an embarrassing subject for patients, it is important for the physician to be aware of/screen for BPH  Tools such as IPSS score/AUA score, DRE, some labs are vital in diagnosing BPH  Deciding whether or not to treat depends on severity of symptoms/pt QOL. Medical and surgical therapies are available.

27. References  BPH-A problem with your prostate, American Family Physician, July, 2002  Managing BPH-When to consider surgery, American Family Physician, May, 2008  Rosenberg MT, Staskin DR, Kaplan A, A practical guide to the evaluation and treatment of male lower urinary tract symptoms in the primary care setting  Up to Date – BPH  Graber MA, Wilbur JK, Family Practice Examination and Board Review