1. BPH Diagnosis and Medical Treatment

2. BPH 85yr : 90% 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

3. LUTS Morbidity & Complication of BPH Mortality of BPH : Rare
LUTS : Bothersome
Highly variable
Treatment :
Patient’s perception
Degree of interfering life style

4. 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

5. LUTS Irritative versus Obstructive Irritative Obstructed
Frequency/urgency/nocturia
Obstructed
Slow stream/stranguria/start-stop
Difficult to distinguish by history alone since symptoms overlap

6. AUA/IPSS Sx Index, Bother
Initial Evaluation
History
DRE & Focused PE UA
PSA in select patients
AUA/IPSS Sx Index, Bother

7. Medical History Surgery, general health
Voiding History: polyuria, stranguria, frequency, urgency post void dribbling
Voiding diary (nocturia)
Urinary Infections :culture
Incontinence

8. Physical Examination DRE Neurologic exam Mental status
Ambulatory status
Neuromuscular function
Anal sphincter tone

9. Urinalysis Bladder cancer, CIS UTI, Urethral stricture
Urethral, bladder stones

10. 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

11. 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

12. 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

13. 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

15. QOL

16. 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

17. Qmax : rate of urine flow
Predict the response to surgery
Predict the natural Hx of BPH
Advantages
LUTS with Normal Qmax : non prostatic cause
Qmax < 10ml/sec : obstruction
Disadvantages
Sx response is not dependent on Qmax
Test / retest variability, lack of well designed study
→ Not feasible to establish cut-point

18. PVR Optional 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

19. 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

20. CMG, IVP, USG of Kidney Not recommended Indicated in Hematuria, UTI
Renal insufficiency, stone Hx, upper tract surgery Hx

22. Initial Management and Discussion of Treatment Options
Watchful waiting
Medical therapy – pills
Minimally invasive surgery
Surgery

24. Treatment Watchful waiting Increase water intake↓
Mild Symptoms
Mod or severe Symptoms without Renal insufficiency, UTI, retention
Increase water intake↓
Decrease alcohol↓, Caffeine↓ SODA
DRE, PSA : suggests natural Hx of Sx
flow rate, AUR, surgery

25. Medical Treatment Options
Alpha-adrenergic blockers
5 alpha-reductase inhibitors
Combination therapies
Phytotherapy

26. 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

27. 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)

28. 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

32. Natural History of BPH PLESS study 1. 3,040 clinical BPH patients
2. IPSS: moderate to severe
3. Qmax: <15 ml/s
4. DRE: enlarged prostate gland
5. PSA <10 ng/ml
(PSA 4-9.9: negative biopsy)
6. Follow-up: 4 years
약 4년전부터 보고되기 시작한 PLESS study는 비록 위약 대조 임상 시험이지만 전립선비대증의 자연사에 대한 유용한 정보를 제공하였습니다.
PLESS study의 결과 중 일부를 간추려 말씀드리도록 하겠습니다.
PLESS study는 임상증상이 있는 3040명의 환자를 대상으로 4년간 장기추적한 study입니다.
환자군은 IPSS가 8점이상이고, Qmax는 15미만이면서 PSA는 10미만으로 전립선암의 증거가 없고 DRE상 전립선의 용적이 크다고 생각되는 환자들이었습니다.

33. Natural History of BPH Risk of Acute Urinary Retention or Surgery
다음의 그림들은 initial PSA의 수치에 따른 acute urinary retention이나 BPH로 인한 수술의 위험도를 Kaplan-Meier curve로 보여주고 있습니다.
그림에서 알 수 있듯이 PSA 수치가 낮을수록 acute urinary retention이나 BPH로 인한 수술의 위험도는 적은 것을 알 수 있습니다.
특히 finasteride는 initial PSA 수치가 높을수록 acute urinary retention이나 BPH로 인한 수술의 위험도를 감소시키는 효과가 더 큰 것을 알 수 있습니다.
참고적으로 말씀드리면 finasteride는 PSA 수치가 0-1.3인 경우 43%, PSA 수치가 인 경우 46%, PSA 수치가 3.2이상인 경우 60%의 acute urinary retention이나 BPH로 인한 수술의 위험도 감소를 보여주었습니다.

34. Natural History of BPH Change of Symptom Score
다음의 그림들은 initial PSA의 수치와 prostate volume에 따른 증상점수의 변화를 보여주고 있습니다.
그림에서 알 수 있듯이 PSA 수치가 낮을수록 placebo에 대한 효과가 커서 증상점수가 많이 호전되며 PSA수치가 3.3 이상인 경우 결국 4년 뒤에는 초기의 증상 정도로 환원된다는 것을 알 수 있습니다.
또한 prostate volume이 작을수록 placebo에 대한 효과가 커서 증상점수가 많이 호전되며 prostate volume이 클수록 증상점수의 호전이 적은 것을 알 수 있습니다.

35. Natural History of BPH Change of Peak Urinary Flow Rate
다음의 그림들은 initial PSA의 수치와 prostate volume에 따른 Qmax의 변화를 보여주고 있습니다.
그림에서 알 수 있듯이 PSA 수치가 낮을수록 placebo에 대한 효과가 커서 Qmax의 호전정도가 크며 PSA수치가 3.3 이상인 경우 결국 4년 뒤에는 초기의 증상보다 더 낮은 urine flow를 갖게 됩니다.
또한 prostate volume이 작을수록 placebo에 대한 효과가 커서 Qmax가 많이 호전되며 prostate volume이 클수록 Qmax는 점차 증가하다가 감소하는 경향을 보이게 됩니다.

36. Surgery Minimally Invasive (office) Surgery (operating room) Microwave
TUNA
Interstitial Laser
Surgery (operating room)
TURP
HOLAP
HOLEP

37. 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

38. Surgery Absolute Indications Relative indications Retention
Repeated infection
Bladder stones
Relative indications
Worsening symptoms
Rising urine retention
Desire to stop medication

39. 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

40. 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

41. Surgery Indicated for urine retention Highest side effects
Possible incontinence
Retrograde ejaculation
Best treatment outcomes
Improves flow rate
Lowers voiding symptoms

42. Recommendations Goal directed therapy
Most patients have a variety of treatment options
Medical management works well for most patients with minimal side effects
Modern procedures are effective and safe
Informed patient decision making : benefits, risks, costs