Urology Update Sanofi- Aventis Kenneth Lim, D.O. Urology Residency Director POH/ Detroit Medical Center

BPH and Aging

Diseases of the Prostate BPH / LUTS / OAB / Retention Signs and Symptoms Medical Management Prostate Cancer Detection

Anatomy of BPH Normal BPH Bladder Hypertrophied detrusor muscle Prostate Urethra Obstructed urinary flow Kirby RS et al. Benign prostatic hyperplasia. Health Press, 1995.

Symptoms Suggestive of BPH Obstructive (Voiding) Weak stream Prolonged micturition Straining Hesitancy Intermittent stream Feeling of incomplete bladder emptying Irritative (Storage) Frequency Nocturia Urgency Incontinence Slide #6: Symptoms Suggestive of BPH Symptoms suggestive of BPH can be divided into two general categories: obstructive and irritative. Obstructive symptoms include weak stream, prolonged micturition, straining, hesitancy, feeling of incomplete bladder emptying, and acute or chronic urinary retention. Irritative symptoms include frequency, nocturia, urgency, and incontinence. The presence of these symptoms, however, does not necessarily mean that the patient has bladder outlet obstruction due to BPH. The physician is obligated to rule out other problems, such as strictures, infections, prostate or bladder cancer, and neurological problems. 6

American Urological Association Symptom Index (AUA-SI) Incomplete bladder emptying Frequency Intermittency Urgency Weak stream Straining Nocturia Most men with BPH have a constellation of symptoms broadly categorized as obstructive or irritative. Obstructive symptoms include hesitancy, weak stream, straining to pass urine, prolonged micturition, feeling of incomplete bladder emptying, and urinary retention. Irritative symptoms include urgency, frequency, nocturia, and urge incontinence.1 Because men may not spontaneously report LUTS, it is important to ask them whether they are experiencing any of these. The severity of LUTS can be evaluated using the American Urologic Association Symptom Index (AUA-SI). The AUA-SI is a seven-item questionnaire that evaluates patients’ symptoms by rating each item on a scale of 0 to 5. The maximum total AUA-SI score is 35. A total AUA-SI score ≤ 7 indicates mild symptoms, 819 indicates moderate symptoms, and 2035 indicates severe symptoms.2 References 1. Kirby RS, McConnell JD. Benign Prostatic Hyperplasia. Oxford, UK: Health Press, 1995. 2. Barry MJ, Fowler FJ Jr, O’Leary MP, et al. The American Urological Association symptom index for benign prostatic hyperplasia. J Urol. 1992;148:15491557. AUA Practice Guidelines Committee. J Urol. 2003;170(2 Pt 1):530537. Barry MJ et al. J Urol. 1992;148:15491557.

AUA Symptom Index (AUA-SI) Classification Mild Moderate Severe AUA-SI 0 – 7 8 – 19 20 – 35 Slide #17: AUA Symptom Index The patient’s symptom index total is matched to the appropriate category, which is either mild, moderate, or severe. A score of 0 to 7 is categorized as mild, 8 to 19 as moderate, and 20 to 35 is categorized as severe. 17

Criteria to Determine Treatment AUA Symptom Score (Quality of Life) Elevated Post-Void Residual UTI Hematuria Bladder calculus Retention

Medical Management for Symptomatic BPH Alpha blockers 5 Alpha reductase inhibitors Combination OAB drugs Observation

Pharmacotherapy of BPH Alpha Blockers 5ARIs Alpha blockers and 5ARIs improve symptoms of BPH in different ways. Alpha blockers quickly relax smooth muscle to rapidly improve urinary symptoms in BPH.1 They do not arrest disease progression.2 The 5ARIs suppress DHT, reduce prostate volume,3 and arrest BPH progression. Only 5ARIs have been shown in clinical studies to arrest the disease process.2 References 1. AUA Practice Guidelines Committee. AUA guidelines on management of benign prostatic hyperplasia (2003). Chapter 1: diagnosis and treatment recommendations. J Urol. 2003;170(2 Pt 1):530537. 2. McConnell JD, Roehrborn CG, Bautista OM, et al, for the Medical Therapy of Prostatic Symptoms (MTOPS) Research Group. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med. 2003;349:23872398. 3. Bartsch G, Rittmaster RS, Klocker H. Dihydrotestosterone and the concept of 5α-reductase inhibition in human benign prostatic hyperplasia. Eur Urol. 2000;37:367–380. Relax smooth muscle Improve symptoms Reduce the prostate volume Improve symptoms Arrest the disease process McConnell JD et al. N Engl J Med. 2003;349:23872398.

Alpha-Blockers (Uroxatral, Flomax) Offers symptomatic relief within days/weeks Does not change size of prostate Side effects Nasal stuffiness, orthostatic hypotension Flomax – retrograde ejaculation Uroxatral – no retrograde ejaculatio Slide #35: Alpha-Blockers: Efficacy The large majority of patients respond quickly (usually within the first few weeks) to a-blockers with a measurable increase in flow rate and significant symptom improvement. 35

5 Alpha Reductase Inhibitor (Proscar, Avodart) Slower effect on urinary symptoms than alpha blockers Prostate size reduction Urinary retention risk reduction

Selection Criteria If Signs & Symptoms – Moderate to Severe (prostate size < 30-40 gms) Alpha blocker - 2 weeks Cystoscopy +/- Prostate Ultrasound If Signs & Symptoms - Moderate to Severe (prostate size > 50 gms Alpha blocker + 5 alpha reductase inhibitor

OAB Drugs Direct action on bladder Storage Urgency, frequency

American Cancer Society Screening Guidelines DRE and PSA - Annually Age 50 – no risk factors Age 40 - Family history of Ca – Breast or Prostate - baseline prostate ultrasound

NEJM 5/04: PSA Inaccurate as Screening Test for Prostate Cancer 15 % of Patients with normal PSA diagnosed with Prostate Cancer PSA – single best test for prostate cancer screening DRE and Prostate Ultrasound to compliment PSA TRUS Biopsy when any abnormality

Age related norms for PSA 40-49 < 2.5 ng/ml 50-59 < 3.5 ng/ml 60-69 < 4.5 ng/ml 70-79 < 6.5 ng/ml

PSA PSA velocity - .75 ng/ ml / year PSA velocity(2-4) - .4 ng / ml / year PSA 4-10 % Free PSA > 20 low risk 10 – 20 intermediate risk < 10 high risk

What to do with an abnormal PSA? 1. Look for a previous PSA, DRE If DRE abnormal, proceed to Biopsy 2. Cipro 500mg BID x 2 weeks 3. Free and Total PSA 4. Assess Cancer Risks for Biopsy 5. Biopsy when in Doubt

Prostate Ultrasound Biopsies Sextant format, local anesthesia, 10-12 biopsies Saturation biopsies – 1 biopsy / gm Indications for biopsies Abnormal PSA – high risk free PSA, PSA density Abnormal DRE Abnormal prostate ultrasound

The Buzz: Robot Prostatectomy Better Cancer Cure Less Impotence, Blood loss Higher Incontinence Shorter Hospitalization

NEJM 4 / 08: Robot vs. Open Prostatectomy Conclusion: No Difference Selection determined by patient bias