BPH Disease Management

7/31/2019 BPH Disease Management

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Benign ProstaticHyperplasia (BPH)

Disease and

Management


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The prostate is an exocrine gland of the male mammalian reproductive

system.

Function

Store and secrete a clear, slightly alkaline (pH 7.29) fluid

The prostate also contains some smooth muscles that help expel

semen during ejaculation

What isprostate?


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A nodular growth of the peri-urethral prostatic tissueMay result in urethral compression, and cause a group of symptoms often

referred to as "prostatism or LUTS

What is BPH?


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BPH Prostate

BPH starts in the inner part of the

gland and as it enlarges, it

squashes the outer part of the gland

into a fairly thin shell, called a

capsule.

BPH never spreads outside the

gland.

These usually develop in the outer

part of the gland and may not block

the urethra at first.

Many men with tumors coincidentlyhave BPH in the inner part of the

gland, and often these BPH

symptoms leads to the cancer being

discovered.

CancerProstate


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The 2 components

Dynamic Component

Increase in prostate bulk Increase in smooth

muscle tone

Normal Hyperplastic

Static Component


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What are the symptoms ofBPH?

O STRUCT S TO S C US


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7OBSTRUCTIVE SYMPTOMS - CAUSED BY BPH

Poor stream The urine flows with less force, traveling only ashort distance, sometimes straight down.

Hesitancy Having to wait for the urine to start flowing.

Terminal dribbling The flow of urine continues after the mainstream has finished, sometimes in spurts ordribbles. Occasionally a second large volumeof urine is passed

Incomplete emptying After finishing, there is a feeling that there isstill urine in the bladder.

IRRITATIVE SYMPTOMS DUE TO OVERACTIVITY OF THE BLADDER

Frequency An abnormally short time betweenpassing urine.

Nocturia Being woken in the night by the need to passurine.

Urgency Being unable to hold on after feelingthe need to pass urine. Can lead tourine leaking (incontinence).

With irritative symptoms, a sensation of incomplete bladder emptying sometimes occurs, even

though the bladder is empty


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How is BPH diagnosed?

AUA Symptom Score (questionnaire)

Medical history

Physical examination Prostate exam

Urinalysis

PSA blood test

Transrectal ultrasound of prostate


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The physical examination

Abdominal examination

Bladder examination with percussion

of the bladder

Digital Rectal Examination (DRE)+++

Fundamental method for assessing the shape and

volume of prostate, benign feels smooth.


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Benign vs Malignant

PSA

Alkaline phosphatase to detect metastasis

Urinary cytology to detect malignant cells

Plain pelvic x-rays to detect bony metastases


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CONDITIONDRE FINDING

Prostatitis soft, boggy and tender

BPH enlarged, smooth, firm

anatomical groove may be felt

Prostate Cancerhard nodular, craggy feel to gland

loss of normal anatomical groove

Digital Rectal Examination (DRE)


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The I-PSS is based on the answers to 7 questionsconcerning urinary symptoms.

Each question is assigned points from 0 to 5 indicating

increasing severity.

The total score can therefore range from 0 to 35

(asymptomatic to very symptomatic).

The I-PSS - symptom assessment

Mild 0-7

Moderate 8-19

Severe 20-35


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The I-PSS Questionnaire (1)

Patient Name: Not at all Less than Less than About More than Almost Your

Date: 1 time half the half the half the always scorein 5 time time time

1. Incomplete emptyingOver the past month, how oftenhave you had a sensation ofsensation of not emptying yourbladder completely after youfinish urinating? 0 1 2 3 4 5

2. FrequencyOver the past month, how oftenhave you had to urinate again lessthan two hours after you finishedurinating? 0 1 2 3 4 5

3. IntermittencyOver the past month, how oftenhave you found you stopped andstarted again several times whenyou urinated? 0 1 2 3 4 5

Not at all

0

0

0

Less than

1 time in 5

1

1

1

Less

than half

the time

2

2

2

More

than half

the time

Almost

always

Your

score

About

half the

time

3

3

3

4

4

4

5

5

5


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Measures peak urinary flow rate (Qmax), voided volume

and micturition time.

A micturition volume of at least 150ml is required for an

adequate analysis

Interpretation of maximum urinary flow rate values:

Uroflowmetry

Normal > 15 ml/s

Equivocal 10-15 ml/s

Obstructed < 10 ml/s


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Post-void residual urine

Useful in the initial diagnostic of BPH and in the follow-up

Determination is best performed by transabdominal

ultrasonography

Abnormal if > 50 - 100 ml on at least 2 measurements (large

intra-individual variability)

Related to bladder outflow obstruction but also detrusor failure,

aging and sensory abnormalities


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-blockers5 -reductase inhibitors

BPH: 3 treatment options

Watchful Waiting

Medical Treatment

Surgery


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Medical Treatment

Symptomatic relief of BPH in patients without an

absolute indication of surgery

Patients in whom surgery is contraindicated

Patients unwilling to go for surgery

Patients awaiting sugery

Prophylaxis for acute urinary retention

bl k h d i


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18-blockers act on the dynamiccomponent of BOO

They reduce the sympathetic tone of the prostate and the

urethra


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Types of Alpha blockers

Uroselective

(new generation)

-blockers mainly

have effect on BOO

Non-uroselective

(old generation)

-blockers also have

an effect on blood

pressure

d i hibi h


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205-reductase inhibitors act on thestatic component of BOO

By inhibiting the production of DHT, they reduce the size

of the prostate


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PgPg 2121

AlfuzosinAlfuzosin (Uroselective alpha blocker)(Uroselective alpha blocker)

IC.ALF.04.06.03

Key Findings from Clinical TrialsKey Findings from Clinical Trials


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PgPg 2222Roehrborn C.Roehrborn C. BJU IntBJU Int2003; 92: 2572612003; 92: 257261

Pooled analysis of 3 double-blindPooled analysis of 3 double-blind

placebo-controlled studiesplacebo-controlled studies

QQmaxmax:: Pooled analysisPooled analysis

ChangeinQ

ChangeinQ

max

max

(ml/s)

(ml/s)

D0D0 D14D14 D28D28

00

0.50.5

1.01.0

1.51.5

2.02.0

2.52.5

3.03.0

pp=0.02=0.02

D84D84

pp


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PgPg 2323

LUTS:LUTS: Pooled analysisPooled analysis

Roehrborn CRoehrborn C et al. BJU Intet al. BJU Int2003; 92: 2572612003; 92: 257261

Pooled analysis of 3 double-blindPooled analysis of 3 double-blind

placebo-controlled studiesplacebo-controlled studies

-7-7

-6-6

-5-5

-4-4

-3-3

-2-2

-1-1

00

D0D0 D28D28 D56D56 D84D84

ChangeinIPSSfromD

0

ChangeinIPSSfromD

0

p


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PgPg 2424

Alfuzosin 10mg ODAlfuzosin 10mg OD

QQmaxmax

0.00.0

0.50.5

1.01.0

1.51.5

2.02.0

< 30ml< 30ml 3040ml3040ml 4060ml4060ml

ChangeinQ

ChangeinQ

max

max

-6-6

-5-5

-4-4

-3-3

-2-2

-1-1

00

Changein

IPSS

Changein

IPSS


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PgPg 2525

Alfuzosin 10mg OD:Alfuzosin 10mg OD: Key FindingsKey Findings

q Good cardiovascular tolerabilityGood cardiovascular tolerability

q Fast improvement of flow rate and LUTSFast improvement of flow rate and LUTS

whatever the prostate sizewhatever the prostate size

IC.ALF.04.06.03


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PgPg 2626

Cardiovascular tolerability

Nordling J.Nordling J. BJU IntBJU Int. 2005 May; 95 (7): 1006-12. 2005 May; 95 (7): 1006-12

Efficacy of Alfuzosin 10 mg OD on QEfficacy of Alfuzosin 10 mg OD on Qmaxmax and LUTS was similar to tamsulosin,and LUTS was similar to tamsulosin,

with no added benefit of the 15 mg dosage vs the 10 mg dosagewith no added benefit of the 15 mg dosage vs the 10 mg dosage

Safety Profile

Alfuzosin 10 mg OD vs. Tamsulosin

PlaceboPlacebon=153n=153

Alf 10Alf 10mgmg

n=154n=154

Alf 15Alf 15mgmg

n=158n=158

Tam 0.4Tam 0.4mgmg

n=158n=158

VasodilatoryVasodilatoryevents n(%)events n(%) DizzinessDizziness HeadacheHeadache HypotensionHypotension SyncopeSyncope MalaiseMalaise

3.9%3.9%3.3%3.3%

000000

5.8%5.8%1.9%1.9%

000000

7.0%7.0%2.5%2.5%0.6%0.6%1.3%1.3%0.6%0.6%

1.9%1.9%4.4%4.4%0.6%0.6%0.6%0.6%

00

OthersOthers Asthenia /Asthenia /

fatiguefatigue

SomnolenceSomnolence

2.0%2.0%1.3%1.3%

2.6%2.6%

6.3%6.3%0.6%0.6%

3.8%3.8%

IC.ALF.04.06.03


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PgPg 2727

SBPSBP SBPSBPDBPDBP DBPDBP

SupineSupine StandingStanding

Blood pressure changes

-6-6

-5-5

-4-4

-3-3

-2-2

-1-1

00

Chang

einbloodpres

sure

Chang

einbloodpressure

PlaceboPlacebo Alfu 10 mgAlfu 10 mg Alfu 15 mgAlfu 15 mg Tamsu 0.4 mgTamsu 0.4 mg

IC.ALF.04.06.03

Nordling J.Nordling J. BJU IntBJU Int. 2005 May; 95 (7): 1006-12. 2005 May; 95 (7): 1006-12


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PgPg 2828



BP changes in elderly ( 65 years)


Chang

einbloodpressure

Chang

einbloodpressure

-8-8

-7-7

-6-6

-5-5

-4-4

-3-3

-2-2

-1-1

00

IC.ALF.04.06.03Nordling J.Nordling J. BJU IntBJU Int. 2005 May; 95 (7): 1006-12. 2005 May; 95 (7): 1006-12


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PgPg 2929



BP changes in men with

anti-hypertensive co-medication

Change

inbloodpress

ure

Change

inbloodpress

ure

-8-8

-7-7

-6-6

-5-5

-4-4

-3-3

-2-2-1-1

00


IC.ALF.04.06.03Nordling J.Nordling J. BJU IntBJU Int. 2005 May; 95 (7): 1006-12. 2005 May; 95 (7): 1006-12

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Surgical treatment

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Indications of surgery

Acute urinary retention

Renal failure secondary to BPH

Recurrent bladder stones

A large residual urineOverflow incontinence

Recurrent urinary tract infections

Very large prostates (generally bigger than 70 grams) aretoo large to safely perform transurethral prostatectomy, and an

open retropubic prostatectomy may be required.

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Complications of surgery

Hemorrhage

Post operative infection

Recurrence: rare, 10-15 yrs

Incontinence: muscle damage

Dysuria: urethral stenosis

Sexual dysfunction: retrograde ejaculation

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TURP (transurethral resection of the prostate)

Gold Standard of care for BPH

Uses an electrical knife (electro-cautery) to surgically cut and

remove excess prostate tissue, tissue and blood vessls sealed

The resectoscope, which is about 12 inches long and 1/2 inch in

diameter, contains a light, valves for controlling irrigating fluid,

and an electrical loop that cuts tissue and seals blood vessels

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The Gold standard- TURP

Advantages

Widely available

Effective

Long lasting

Disadvantages

Greater risk of side effects

and complications

1-4 days hospital stay

1-3 days catheter

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Possible side effects ofTURP

Impotence

Incontinence

Bleeding

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Transurethral Microwave Therapy

(TUMT)

Transurethral Needle Ablation

(TUNA)

Green light laser

Minimally InvasiveTherapy

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Thank you!

BPH Disease Management

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