1. The Aging Prostate: Presentation, Diagnosis & Management Professor Riyadh F. Talic, MD Professor of Urology & Andrology College of Medicine, King Khalid University Hospital And Consultant Urologist & Andrologist at Specialized Medical Center, SMC

2. Etiology of BPH Increasing Age Testosterone

3. Prevelance of BPH & Aging 60 yrs 50% At 80 yrs 88%

4. Aging Prostate Terminology Benign Prostatic Hypertrophy (BPH) Benign Prostatic Obstruction (BPO) Lower Urinary tract symptoms (LUTS)

5. Benign Prostatic Hypertrophy LUTS BPH Bladder dysfunction Urinary Obstruction

6. Prostatic LUTS Storage LUTS (i.e. irritative LUTS) : –Frequency –Nocturia –Urgency –Urge incontinence Voiding LUTS (i.e. obstructive LUTS): –Hesitancy –Weak stream –Intermittency –Sense of incomplete emptying

7. Causes for Storage LUTS (Irritative LUTS) Urinary Outflow Obstruction Locally irritating pathology Neuro-vesical dysfunction Cystitis Tumors Stones

8. Adverse effects of BPH Erodes Quality of Life Complications: –Urinary retention –Recurrent hematuria –Bladder stones –Compromised renal function

9. BPH effects on Quality of Life Limits fluids before travel 58% Limits fluids before bed time 63% Cannot drive for more than 2 hours 51% Not getting enough sleep at night 51% Avoids places without toilets 62% Limits playing outdoor sports 33% Tsang et al: Prostate 1993

10. Evaluation of patients with BPH Digital rectal examination (size not relevant) Urinalysis (pyuria, microhematuria) Urine Cytology (in patients & irritative LUTS) Prostate Specific Antigen (PSA) Urine Flowmetry U/S KUB & post void residue estimation

11. Management Options for patients with BPH Medical therapy Instrumental ( minimally invasive) therapy Surgical therapy

12. Medical Therapies for BPH is the first line of management of patients with symptomatic BPH

13. Medical Therapies for BPH 5 α reductase inhibitors: – Finasteride (Proscar). Alpha- blockers: – Trazosin (Itrin). – Doxazosin (Cardura). – Alfuzosin (Xatral). – Tamsulosin (Flomax, Omnic).

14. Finasteride (Proscar). 5 α reductase inhibitors offer medical prostatectomy. Need 6/52 for patients to realize benefits. Valuable in large prostate > 50 gms. Adverse effects: –Erectile dysfunction. –Retrograde ejaculation. –Teratogenic effects on Fetus ? –Alters PSA levels.

15. Alpha- blockers Alpha- blockers act on α-receptors in the BN & Prostatic capsule. Rapid onset of action (within 2/52). Enhances sexual function ?? Adverse effects: –Postural Hypotension. –Retrograde ejaculation.

16. Frequency of Sexual Intercourse per Month in Men 50-80 years 8.6 4.9 5.7 3.7 4.0 1.7 N=12,815 Paolo:EAU,Birmingham 2002

17. Percentage of Men Aged 50-80 Years & No or Net reduced Semen 64 78 89 18 37 47 N=11,063 Paolo, EAU; Birmingham 2002

18. Effect of Alfuzosin on the number of erections induced by Apomorphine Number of Erections McKenna: EAU, Birmingham, 2002

19. Which Alpha- blocker ? Efficacy (Uro-selectivity ?) Dosing – Single dose / Day – No need for titration Minimal side effects – Postural hypotension – No retrograde ejaculation Cost of the treatment

20. Minimally Invasive Therapies for BPO TUIP (Incision) Prostate balloon dilatation Urethral (prostatic) stents Hyperthermia Cryosurgery TUNA Laser devices

21. Surgical Therapy for BPO Based on removal & debulking of the obstructing prostatic adenoma, indicated in: – Failed medical treatment – Complications: Urinary retention. Renal back pressure changes. Hematuria. Large vesical stones.

22. Surgical Therapy of BPO Open prostatectomy Transurethral prostatectomy – TURP (Resection) – TUVP (Vaporization) – TUVRP (Vaporization- Resection)

23. Transurethral resection of the Prostate (TURP) using a standard wire loop and electrosurgical unit is still regarded as the “Gold Standard” in the treatment of men with BPO

24. Morbidity associated with TURP Bleeding TUR syndrome (Low serum sodium) Infection Urinary incontinence Erectile dysfunction.

25. Transurethral Vaporization Resection Prostatectomy (TUVRP) Thick Loop (Resection) Augmented Electocutting energy (Electrovaporization) TUVRP = TURP + TUVP Technique of operation!

26. TUVRP TUVRP improves safety of transurethral prostatectomy and has the potential to reduce the main 2 morbidities that are associated with standard TURP namely; bleeding and electrolyte disturbances.

27. TUVRP The shorter post operative catheterization time that is noted following TUVRP is clinically significant considering the demand for lower morbidity profiles and hospitalization time by the patients and health care providers

28. Conclusions Symptomatic BPH affects men over 40 years of age and erodes their quality of life

29. Conclusions Pre treatment evaluation of patients is necessary to rule out other pathology that needs a different therapeutic approach

30. Conclusions Alpha- blockers should be the first line of treatment in every patient that is presenting with BPH with the aim of restoring quality of life and Sexual function

31. Conclusions The Alpha-blocker of choice should be efficacious, once daily dose (with no titration), No sexual adverse effects and cost effective

32. Conclusions Patients that fail medical treatment or develop complications related to BPH should be referred to the Urologist for further work-up and interventional managment