1. BPH – From Diagnosis To Treatment Strategies in GP Practice
Kashifuddin Qayoom Soomro
Assistant Professor
Department of Urology
Liaquat University of Medical & Health Sciences Jamshoro

3. BPH and prevalence The most common benign tumor in men.
Half of all men over the age of 60 will develop an enlarged prostate
By the time men reach their 70’s and 80’s, 80% will experience urinary symptoms n n

4. BPH is a very frequent condition in ageing men
Prevalence of BPH
90%
50%
20% 0%
< 30 years
41-50 years
51-60 years
> 80 years

5. What causes BPH?
BPH is part of the natural aging process, like getting gray hair or wearing glasses
BPH cannot be prevented
BPH can be treated n n

6. The lower urinary tract symptoms (LUTS)
BPH
Bladder Outlet
Obstruction (BOO)
Impaired detrusor
contractility
Involuntary
bladder
contraction
Voiding symptoms
- hesitancy
- weak stream
- prolonged voiding
- post voiding dribbling
- feeling of incomplete emptying
Decreased flow rates
Post void residual urine
Storage symptoms
- urge
- frequency
- nocturia
- urge incontinence

7. BPH/LUTS is largely undertreated
Percentage of men who receive medical treatment for their LUTS by LUTS severity
LUTS
Age
Rosen et al. Eur Urol 2003; 44:

8. The Diagnosis of BPH

9. The patient’s initial evaluation
The basic evalution should be done on every patient presenting to a health care provider with LUTS:
Medical history
Assessment of symptoms and bother
Physical examination (DRE)
Urinalysis
Serum Prostate-Specific Antigen (PSA)*
Frequency-Volume Chart (to differentiate between nocturia and polyuria)
*not in all patients

10. The medical history of the patient
Nature and duration of LUTS
Previous surgical procedures
General health issues, sexual function history
Medications currently taken by the patient
The patient’s fitness for possible surgical procedures or other treatments

11. The International Prostate Symptom Score (IPSS)
The I-PSS is based on the answers to 7 questions concerning 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 severely symptomatic).
Mild
0-7
Moderate
8-19
Severe
20-35

12. The International Prostate Symptom Score (1)
Not at all
Less than
1 time in 5
Less than
half in the
time
About
half the
time
More than
half the
time
Almost
always
Patient name:
Date
1. Incomplete emptying
Over the past month, how often
have you had a sensation of not emptying your bladder completely after you finish urinating?
2. Frequency
have you had to urinate again less than two hours after you finished
urinating?
3. Intermittency
have you found you stopped and
started again several times when
you urinated? 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

13. The International Prostate Symptom Score (2)
Patient name:
Date
4. Urgency
Over the past month, how often have you found it difficult to postpone urination?
5. Weak stream
Over the pas month, how often have you had a weak urinary stream?
6. Straining
Over the past month, how often have you had to push or strain to begin to urinate?
7. Nocturia
Over the past month, how many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?
Not at all
Less than
1 time in 5
Less than
half in the
time
About
half the
time
More than
half the
time
Almost
always 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

14. The bother score (IPSS 8th question)
Patient name:
Date
1. If you were to spend the rest
of your life with your urinary
condition just the way it is now,
how would you feel about that?
Delighted
Pleased
Mostly
satisfied
Mixed about equally satisfied and dissatisfied
Unhappy
Terrible 1 2 3 4 5
BOTHER SCORE (BS) =

15. Disease specific quality of life and sexual function
No recommended questionnaire in routine practice
Sexual function questionnaires used exclusively in clinical trials (IIEF, DAN-PSSsex, BSFI, MSHQ…)

16. The physical examination
1. Abdominal examination
 rule out other possible urinary
or rectal conditions
2. Digital Rectal Examination
(DRE)
 fundamental method for
assessing the shape and the
volume of the prostate

17. Urinalysis Standard examination for the detection of: - Haematuria,
- Proteinuria,
- Pyuria,
4-5% of men with microscopic haematuria will be found to have a cancer or other urological disease within the first 3 years following the test.

18. Serum Prostate-Specific Antigen (PSA)
Measurement recommended for patients with at least 10-year life expectancy and for whom knowledge of the presence of prostate cancer would change management
PSA is also a proxy of prostate size but its variability is high. Recent studies suggest that it may be used to predict the risk of AUR and BPH-related surgery.

19. Frequency - volume chart
Measurement useful when nocturia is the predominant symptom
To identify patients with nocturnal polyuria excessive fluid intake

20. Referral to the specialist
If treatment fails and the patient is not satisfied, the patient should be referred to a urologist for further evaluation and possibly interventional treatment
Detailed quantification of symptoms by standardized questionnaires
Flow rate recording
Residual Urine measurement
Pressure flow studies

21. BPH Treatments

22. Treatment objectives
1. Provide rapid and sustained relief of symptoms.
2. Act on the course of the disease by preventing long-term complications.
3. Respect patients’ Quality of Life and sexual function.

23. The BPH patient is basically offered 3 treatment options:
Watchful Waiting
Surgery
Medical Treatment

24. Definition of watchful waiting
The patient is instructed on behavioural techniques to reduce symptoms (reduction of fluid intake at bedtime, reduction of alcohol and caffeine consumption…).
The patient’s symptoms and clinical course should be monitored, usually annually.

25. Indications of watchful waiting
Uncomplicated BPH
Symptoms not bothersome (usually IPSS ≤7)
Symptoms significantly bothersome but after being informed of various treatment options and their consequences, the patient chooses watchful waiting

26. Indications of medical treatment
Uncomplicated BPH
Symptoms are bothersome (usually IPSS>7) and after being informed of various treatment options and their consequences, the patient chooses medical treatment

27. There are 2 pharmacological classes used in BPH
1-blockers
5-reductase inhibitors

28. The 2 components of BOO Static Component Dynamic Component
Normal Hyperplastic
Increase in
prostate bulk
Increase in
smooth muscle tone

29. 5-reductase inhibitors act on the static component of BOO
By inhibiting the production of DHT, they are expected to reduce the size of the prostate.

30. But … Delayed onset of action Less effective than α1-blockade on LUTS
Need 6 to 12 months to significantly improve LUTS
Less effective than α1-blockade on LUTS
Improve IPSS of 3 to 4 points
More effective for enlarged prostates
(> 40g)

31. 1-receptors are abundant in the bladder neck, prostate and urethra
They are sparse in the bladder body

32. 1-blockers act on the dynamic component of BOO
1-blockers are expected to reduce the sympathetic tone of the prostate and the urethra.

33. 1-blockers may have local but also systemic effects
URINARY TRACT EFFECT
 Voiding
Symptoms
Prostate
Urethra
Bladder Neck
 Outflow
resistance
 Flow
Rates
 Residual
Urine
Bladder
 Bladder
Instability
 Filling
Symptoms
SYSTEMIC EFFECT
Blood vessels
 Blood
Pressure
Postural
Hypotension
Dizziness

34. Uroselectivity is the capacity to achieve more local than systemic effects
Uroselective (new generation)
1-blockers mainly effective on the lower urinary tract
Non-uroselective (old generation)
1-blockers primarily developed for the treatment of hypertension

35. New generation (uroselective) 1-blockers
Terazosin (HYTRIN)
Doxazosin
Alfuzosin Tamsulosin
Recent molecules
Few cardiovascular & CNS side effects

36. Benefits of 1-blockers in BPH
Rapid onset of action
From the first dose on peak flow rate for terazosin ( Hytrin ), alfuzosin1 and tamsulosin2,
From the first days on LUTS
Best monotherapy for relief of LUTS3
Improvement of IPSS of 4 to 6 points
Effective irrespective of prostate size
Improve quality of life and respect sexual function
1Marks et al. Urology 2003, 62,
2Lepor Urology 1998, 51,
3AUA Practice Guidelines Committee, J.Urol 2003, 170,

37. Benefits of 1-blockers in BPH
Facilitate catheter removal with return to normal voiding in men with AUR1
Reduce BPH progression:
Terazosin ( Hytrin ), Alfuzosin and doxazosin do not prevent the occurrence of AUR2-3.
However, Terazosin ( Hytrin ) alfuzosin and doxazosin significantly reduce deterioration of LUTS compared with placebo2-3.
1McNeill et al. Urology 2005, 65, 83-90
2McConnell et al. NEJM 2003, 349,
3Roehrborn et al., BJU Int 2006, 97,

38. Complicated BPH Bladder stones Recurrent haematuria
Acute Urinary Retentions
Damage to kidneys
Urinary tract infections

39. Surgical Treatments Open prostatectomy
Transurethral Resection of the Prostate (TURP)
Transurethral Incision of the Prostate (TUIP)
Transurethral Microwave Thermotherapy (TUMT)
Transurethral vaporization of the prostate (TUVP)
Transurethral needle ablation of the prostate (TUNA)

40. CONCLUSION Every male > 50 yrs of age should be evaluated
To exclude possibility of Ca prostate
To exclude complication resulting from BPH
To improve the quality of life of patients having LUTS with medical therapy

41. Thanks