1. All About the Prostate For Intelligent Internists
Part 1: Benign Prostatic
Hyperplasia

2. Objectives
Part A: Diagnosis Formulate a differential diagnosis for LUTS Perform appropriate evaluation/ w/u Use the AUA symptom score to assess severity Part B: Management  counsel on what to expect from medications  appropriately manage persistent symptoms

3. Diagnosis: MKSAP!
An 80-year-old man is evaluated for a 1-year history of progressive urinary symptoms including weak stream, hesitancy, and nocturia four times nightly. He has coronary artery disease and chronic heart failure. His current medications are lisinopril, isosorbide dinitrate, aspirin, and metoprolol.
On physical examination, vital signs are normal. He has mild suprapubic tenderness and a symmetrically enlarged prostate without nodules or tenderness. The remainder of the physical examination is normal.
Which of the following is the most appropriate diagnostic test to perform next?
A. Postvoid residual urinary volume measurement
B. Plasma glucose level
C. Prostate-specific antigen testing
D. Transrectal ultrasound
E. Urinalysis

4. Anatomy of a large prostate
Prevalence: 25% of men in 40s, 80% in 70s
not all are symptomatic

5. LUTS! More than half of men in their 60s have LUTS LUTS ≠ BPH
Storage, Voiding, Postmicturition Sx
Differential Diagnosis
bladder irritants (e.g. caffeine, alcohol) or excess fluid
Diuretics, anticholinergic, antihistaminic meds
UTI/prostatitis
Overactive Bladder
Neurogenic Bladder (e.g. parkinson’s, spinal cord)
Bladder, prostate Ca

6. Workup U/a generally indicated
(eval for UTI/hematuria)
*Consider* DRE/PSA to evaluate for prostate ca after discussing risks/harms
Might also consider DRE to evaluate prostate size as it pertains to management
PVR if sensation of incomplete emptying (or renal insufficiency and suspect postrenal issue)

7. Diagnosis: MKSAP!
An 80-year-old man is evaluated for a 1-year history of progressive urinary symptoms including weak stream, hesitancy, and nocturia four times nightly. He has coronary artery disease and chronic heart failure. His current medications are lisinopril, isosorbide dinitrate, aspirin, and metoprolol.
On physical examination, vital signs are normal. He has mild suprapubic tenderness and a symmetrically enlarged prostate without nodules or tenderness. The remainder of the physical examination is normal.
Which of the following is the most appropriate diagnostic test to perform next?
A. Postvoid residual urinary volume measurement
B. Plasma glucose level
C. Prostate-specific antigen testing
D. Transrectal ultrasound
E. Urinalysis

8. AUA Symptom Score/I-PSS
Part of initial evaluation that can help confirm dx and guide management
35 point scale
In prism: .aua
Used to evaluate response to therapy
3-4 point difference clinically significant

10. Objectives
Part A: Diagnosis Formulate a differential diagnosis for LUTS Perform appropriate evaluation/ w/u Use the AUA symptom score to assess severity Part B: Management  counsel on what to expect from medications  appropriately manage persistent symptoms

11. Management: MKSAP!
A 68-year-old man is evaluated for continuing urinary frequency and nocturia. His symptoms have been slowly progressive over the past 1 to 2 years with a weak urinary stream and hesitancy. He was started on doxazosin 6 months ago, which he tolerates well and initially provided some improvement. However, his symptoms have continued and are beginning to interfere with his quality of life, particularly the urinary frequency and nocturia. His only other medical problem is hypertension, for which he takes lisinopril and metoprolol.
On physical examination, he is afebrile, blood pressure is 140/85 mm Hg, pulse rate is 70/min, and respiration rate is 14/min. BMI is 25. He has a symmetric moderately enlarged prostate gland with no prostate nodules or areas of tenderness. A urinalysis is normal.
Which of the following is most appropriate next step in treatment of this patient's benign prostatic hyperplasia?
A. Add finasteride
B. Change doxazosin to finasteride
C. Change doxazosin to tamsulosin
D. Prescribe a fluoroquinolone antibiotic for 4 weeks

12. Management AUA < 8 -> watchful waiting usually appropriate
AUA >8 usually med mgmt
Keep it patient centered! depends on how bothersome sx are.
Absolute indications for treatment?
Postrenal AKI
Urinary retention (PVR >250? 300?)
Bladder stones
Recurrent UTIs

14. Alpha-1 blockers All equally effective in head to head studies
More efficacious than finasteride for reducing symptoms
Selective have a better safety profile, but more $

15. 5-α reductase inhibitors
Finasteride/Dutasteride
Decreases size of prostate (part of inclusion criteria for studies: prostates>30 g on US, PSA >1.5)
5-year trial shown to decrease risk of urinary retention and surgery
Takes ~6 months for improvement in AUA score
Side Effects
Decreased libido, ED, gynecomastia
Will decrease PSA by ~50% at 6 months
May reduce incidence of prostate cancer overall but increase risk of high grade prostate ca

16. Combination therapy
One-year trial 1996 showed combination therapy not superior to terazosin alone in reducing symptom scores and urinary flow rates
MTOPS trial 2003:
mean f/u 4.5 years
AUA score 8-30
Composite Primary Outcome: Clinical progression
increase in AUA score ≥4, acute urinary retention, renal insufficiency, incontinence, recurrent UTI
Secondary outcomes: improvement in AUA score

20. MTOPS Take-Homes
Significant reduction in composite clinical progression with combination than either doxazosin or finasteride alone  not better than alpha blocker alone in preventing progression of AUA scores (although AUA more improved by year 5 with combo vs. doxazosin alone: -7 points vs. -6) not better than finasteride alone in risk of urinary retention/invasive therapy  more AEs, more $ Who might you choose combo tx for? failure of alpha blocker tx alone large prostate size/higher PSA? higher AUA score? Urinary retention?

21. Other options Antimuscarinics (oxybutynin)
If predominantly storage sx (frequency, urgency)
In men with PVR <250, reduced symptoms when added to α –blocker, did not increase risk of retention
PDE inhibitors (tadalafil 5 mg daily)
PDE present in prostatic tissue: PDE-I may enhance smooth muscle relaxation, decrease proliferation of hyperplasia
Reduced AUA score 3.8 points at 12 weeks
Saw Palmetto? Data does not show efficacy

22. When to Refer to Urology
Refractory sx
Urinary retention
recurrent UTIs
Rising PSA if you choose to monitor (e.g. on 5-alpha reductase inhibitor)

23. Management: MKSAP!
A 68-year-old man is evaluated for continuing urinary frequency and nocturia. His symptoms have been slowly progressive over the past 1 to 2 years with a weak urinary stream and hesitancy. He was started on doxazosin 6 months ago, which he tolerates well and initially provided some improvement. However, his symptoms have continued and are beginning to interfere with his quality of life, particularly the urinary frequency and nocturia. His only other medical problem is hypertension, for which he takes lisinopril and metoprolol.
On physical examination, he is afebrile, blood pressure is 140/85 mm Hg, pulse rate is 70/min, and respiration rate is 14/min. BMI is 25. He has a symmetric moderately enlarged prostate gland with no prostate nodules or areas of tenderness. A urinalysis is normal.
Which of the following is most appropriate next step in treatment of this patient's benign prostatic hyperplasia?
A. Add finasteride
B. Change doxazosin to finasteride
C. Change doxazosin to tamsulosin
D. Prescribe a fluoroquinolone antibiotic for 4 weeks