1. Benign Prostate Hypertrophy (BPH)

2. Introduction Benign prostatic hyperplasia refers to nonmalignant growth of prostate. – age-related phenomenon in nearly all men, starting at approx 40 years of age. Histologically – 10% of men in their 30s – 20% in 40s – 50-60% in 60s – 80-90% in their 70s and 80s. Prostate size increases from – 25g to 30g for men in 40s – 30g to 40g in 50s – 35g to 45g in 60s.

3. Introduction However, many men with histological BPH may never develop symptoms, which is when treatment is sought. Etiology – poorly understood despite decades of intense research – hyperplasia thought to be stimulated by dihydrotestosterone (DHT) Additional risk factors: positive family history

4. Symptoms Lower urinary tract symptoms (non-specific, can also include those with prostatitis, prostate cancer, bladder outlet obstruction like urethral stricture, stones, etc.) Hesitancy, frequency, urgency, straining, weak flow, prolonged voiding, partial or complete urinary retention, small voided volumes, nocturia, painful urination. If peak urinary flow rate <10 mL/s, then subvesical obstruction seen in 90% patients Risk factors: changes to bladder anatomy and function, UTI, formation of bladder stones, renal failure

5. Diagnosis Careful history and physical examination including DRE DRE notoriously unreliable in assessing size, in fact, shown to underestimate size of prostate Still important because some men found to have prostate cancer based on DRE UA, serum Cr. PSA depending on patient’s life expectancy and circumstances. – PSA is an individualized decision to be made with patient and physician

6. Diagnosis Further evaluate with AUA Symptom Score, or International Prostate Symptom Score (IPSS)—7 questions each on severity scale of 0-5: frequency, nocturia, weak urinary stream, hesitancy, intermittence, incomplete emptying, and urgency. If score <8, mildly symptomatic and recommend yearly reevaluation If 8-35, may consider additional tests if history confounded by neurological diseases, prior failed BPH therapy, and those considering surgery. Optional tests: – Urinary flow rate <10 mL/s highly suggestive of outlet obstruction – Postvoid residual urine measurement with transabdominal ultrasound or in-and-out catheterization.

8. Management If no obstruction and limited discomfort, do not need to treat!!

9. Non-pharmacological Management · Mild symptoms or limited discomfort? o Watchful waiting and annual evaluation o Lifestyle Modifications  Avoid fluids prior to bedtime or going out  Reduce caffeine and alcohol  Scheduled urination at least once every 3 hours.  Double voiding: after urinating, wait and try to urinate again.

10. Pharmacological Treatment Alpha-1-adrenergic antagonists – Relax smooth muscle in the bladder neck, prostate capsule, and prostatic urethra – Immediate relief! – Examples Terazosin, Doxazosin – Initiate at bedtime (hypotension) Tamsulosin, Alfuzosin – Lower potential to cause hypotension, syncope – Minor differences in the adverse events profiles, equal clinical effectiveness – Major Side Effects HYPOTENSION! Ejaculatory Dysfunction (particularly Tamsulosin) Interaction with phosphodiesterase-5 inhibitors – Potentiated effects of hypotension – Separate doses by at least 4 hours

11. Pharmacological Treatment 5-alpha-reductase inhibitors – Reduces the size of the prostate gland – Prevents conversion testosterone  dihydrotestosterone (DHT) – ~ 6 to 12 months before prostate size is sufficiently reduced to improve symptoms!! – Indefinite treatment, as discontinuation may lead to symptom relapse. – Examples Finasteride (initiated and maintained at 5 mg once daily) Dutasteride – Side Effects Sexual dysfunction Decrease PSA – Take into account during interpretation

12. Pharmacological Treatment Anticholinergics – monotherapy for patients with predominately irritated symptoms related to overactive bladder – Frequency, urgency, incontinence – Examples Oxybutynin, Tolterodine – Side Effects Extensive! Dry mouth, blurred vision, tachycardia, constipation etc

13. Pharmacological Treatment Combination therapy – Severe symptoms without maximal response to maximal monotherapy – Alpha 1 and anticholinergics – Alpha 1 and reductase inhibitors

14. If still fails? If all else fails: Surgery or Minimally Invasive Surgical Therapies – Many surgical/interventional options – MIST Transurethral needle ablation (TUNA), transurethral microwave therapy (TUMT), Transurethral Electroevaporation of The Prostate TUVP – Surgery Open Prostatectomy – Endoscope Transurethral Incision of the Prostatce (TURP)

15. Management When to get Urology involved? – Bladder Obstruction syndrome – Men <45 years old – Presence of hematuria in the absence of infection – Abnormality on prostate exam (nodule, induration, or asymmetry) – Men with incontinence – Severe symptoms

17. References Roehrborn CG. Benign prostatic hyperplasia: an overview. Rev Urol. 2005;7 Suppl 9:S3-S14. McVary KT, Roehrborn CG, Avins AL, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol. 2011 May;185(5):1793-803. doi: 10.1016/j.juro.2011.01.074. Epub 2011 Mar 21.