1. Canadian Undergraduate Urology Curriculum (CanUUC): Prostate Diseases
Last reviewed May 2017

2. Prostate 1: LUTS/Benign Prostate Hyperplasia

3. Objectives
Describe the lower urinary tract symptoms (LUTS) found in men with BPH.
Outline the investigations required when evaluating a man with LUTS.
Describe the medical treatments of BPH.
Describe the indications for surgical treatment of BPH.

4. Benign Prostatic Hyperplasia
Commonly associated with “voiding” & urinary “storage” symptoms
Epidemiology
Extremely common with 70% of men in their 70’s describing voiding symptoms

5. Benign Prostatic Hyperplasia: Pathophysiology
Prostate volume increases from puberty
Androgen dependent
Symptoms correlate with gland size, but not strongly
Static compression of the urethra
Glandular volume
Dynamic compression of the urethra
Smooth muscle component of prostate stroma
Hypertrophied detrusor muscle
Obstructed urinary flow

6. Lower Urinary Tract Symptoms (LUTS)
Storage Symptoms
Frequency
Urgency ± urge incontinence
Nocturia
Voiding Symptoms
Hesitency
Decreased stream
Straining to void
Incomplete emptying
Urinary retention
Overflow incontinence
*LUTS does not equate to BPH but BPH is the most common cause of LUTS*

7. Differential Diagnosis of LUTS
Multiple problems can co-exist
Pre-Prostatic Causes
Stones/Tumors
Infections/inflammatory conditions
Neurogenic Bladder (spinal cord injuries, MS, Diabetes, etc)
Atonic Bladder /Overactive Bladder
Polyuria/Polydypsia
Prostatic Causes
BPH
Prostatitis
Prostate Cancer (advanced)
Post-Prostatic Causes
Urethral Stricture
Meatal Stenosis

8. Evaluation: Medical History
Should focus on:
Urinary tract symptoms
UTI, Hematuria
Previous surgery
Family history of prostate carcinoma
Co-morbidities/general health issues
Medications (Anti-cholinergics & sympathomimetics)
Voiding diary (optional)

9. Evaluation: Physical Examination
Complete exam including:
Abdomen (assess bladder)
External genitalia
Focused neurological exam
Digital Rectal Examination (DRE)
(Assess for concurrent disease)

10. BPH: Recommended Investigations
Urinalysis and culture
Prostate Specific Antigen (PSA)(if appropriate)
International Prostate Symptom Index (or AUA symptom index)
Serum Creatinine (optional)

11. American Urological Association Symptom Index (AUA-SI)
Incomplete bladder emptying
Frequency
Intermittency
Urgency
Weak stream
Straining
Nocturia
AUA Practice Guidelines Committee. J Urol. 2003;170(2 pt 1):530537.
Barry MJ et al. J Urol. 1992;148:15491557.

12. LUTS: Optional Investigations
Cystoscopy (only if):
If urinalysis abnormal (hematuria or pyuria)
Patient <50 years old
Renal Ultrasound (only if):
If serum Cr elevated
PVR urine/Uroflow (optional)
Urodynamic’s (if)
Atypical symptoms or neurologic disease
Incontinence (male)

13. LUTS: Treatment Options
Lifestyle Measures
Watchful Waiting
Medical Management
Alpha blockers
5-alpha reductase inhibitors (5 ARI’s)
PDE5 inhibitors (Tadalafil 5mg po qDay)
Surgical Management

14. 1. Treatment Options: Lifestyle Measures
Fluid modification
Reduce fluid intake in the evening
Avoid caffeine, alcohol
Timed voiding
Regular timed voiding of the bladder
Modify medications
I.e: change time of dosing diuretics
Avoid cold remedies (anti-histamines)
Avoid anti-cholinergics
Avoid alpha-agonists (i.e. decongestants)

15. Treatment Options: Herbal Supplements
Herbal: Commonly available OTC supplements
Saw palmetto extract (Serenoa repens)
(Recent NEJM Paper cited no proven benefit)
Pumpkin seed (no evidence)
Pygeum africanum (African Plum)
Mineral:
Zinc (however, no proven benefit)
Wilt TJ, et al. JAMA. 1998;280:1604-9;
Barry MJ. BMJ. 2001;323:

16. 2. Treatment Options: Watchful Waiting
Patient monitored by physician without active intervention for LUTS
Safe in patients with mild, stable symptoms
Intervene when symptoms worsen or complications arise such as acute retention, recurrent hematuria, recurrent UTI, hydronephrosis, bladder calculi

17. 3a. Medical Treatment: Long-acting Non-selective 1-blockers
The prostate has a muscular “dynamic” component (centrally)
These fibers are alpha-receptor mediated

18. 3a. Medical Treatment: Long-acting Non-selective 1-blockers
Dosage is increased in a stepwise fashion at weekly intervals
Does not affect PSA
Acts to relax prostatic/bladder neck smooth muscle (& vascular smooth muscle - non selective)
Doxazosin (Cardura)
Dosage: 1-2 mg qDay, titrate up to 4-8 mg OD
Terazosin (Hytrin)
Dosage: 1 mg OD, titrate up to 2, 5, or 10 mg
Not usually first line anymore

19. 3a. Medical Management: Long-acting Selective 1A-blockers
Long-acting selective 1-blockers
Specifically relaxes the smooth muscle of the prostate and bladder neck
Does not interfere with bladder contractility
Does not affect PSA
Alfuzosin (Xatral)
Dosage: 10 mg qDay
Tamsulosin (Flomax)
Dosage: 0.4 mg qDay
Silodosin (Rapaflo)
Dosage: 8mg qDay

20. 1-Blockers: Side Effects
5 known side effects of alpha blockade for LUTS
Asthenia
Hypotension
Retrograde ejaculation
Dizziness
Flu-like syndrome

21. 3b. Medical Management: The 5--reductase Inhibitors
Regulate androgen available to prostate by blocking conversion of testosterone to dihydrotestosterone (DHT)
Slow the rate of prostate enlargement
Reduce prostate volume and relives “static” compression by BPH
Reduce PSA by ~50%
Takes 3-6 months to exert clinical effect

22. 5--reductase Inhibitors
Men with larger prostates (> 40 g) respond most favorably
Finasteride (Proscar)
Dosage: 5 mg OD – type II inhibitor
Dutasteride (Avodart)
Dosage: 0.5 mg OD – type I and II inhibitor

23. 5--reductase Inhibitors: Side Effects
This shows the numbers but makes them appear in context (that is, only a small proportion of men get these symptoms, the faded green bars imply the unaffected majority of men)
*percentages reflect upper estimates of incidence

24. 3c. Medical Management: Daily PDE5 Inhibitor
Tadaladfil 5mg qDay:
Improves male LUTS
Exact mechanism unknown
Helps concurrent erectile dysfunction
May potentiate hypotension in men taking concurrent alpha-blockers

25. 4. LUTS: Indications for Surgery
Bothersome symptoms despite treatment
BPH-related complications
Urinary Retention (inability to void)
Bladder calculi
Recurrent UTI
Recurrent hematuria from the prostate
Upper tract dysfunction (hydronephrosis, renal dysfunction)
Surgical approach will depend on:
Patient’s prostate size
Surgeon’s judgment
Patient’s co-morbidities
Good place to highlight the etiology of many of these problems – retained urine predisposes to infection and calculi, increased bladder pressures result in uper tract deterioration and worsening distension leads to retention

26. BPH Surgery: Transurethral Resection of Prostate (TURP) is the Most Common Surgery for BPH
Transurethral resection of the prostate (TURP)
Standard of care
Uses electrosurgery to “core” out the obstructive tissue

27. LUTS: Surgical Techniques
TURP - Transurethral Resection of Prostate
Gold standard for surgical treatment of BPH if prostate has moderate size
Minimally invasive surgeries
Numerous laser vapourization techniques
Open prostatectomy to remove the central/transtion zone when prostate is very large (>100cc)

28. Complications: TURP
Retrograde ejaculation (very common>90%)
Incontinence (1-2%)
Erectile Dysfunction (rare)
Bladder neck Contracture/Urethral Stricture (1-10%)
Bleeding (~5% need a transfusion)
Risks of any Operation

29. Treatment of BPH: Summary
Watchful Waiting
Patients with mild symptoms
Alpha Blocker
Relaxes prostatic smooth muscle
Rapid relief of symptoms (within 2 weeks)
May not address eventual progression
5--reductase inhibitor
Decreases prostate volume
“Slower” acting (3-6 months)
May reduce risk of progression
More suitable for larger prostates
Combination Therapy