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

3. BPH and Aging

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

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

6. 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

7. 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.

8. 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

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

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

11. 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.

12. 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

13. 5 Alpha Reductase Inhibitor (Proscar, Avodart)
Slower effect on urinary symptoms than alpha blockers
Prostate size reduction
Urinary retention risk reduction

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

15. OAB Drugs
Direct action on bladder
Storage
Urgency, frequency

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

17. 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

18. Age related norms for PSA
< ng/ml
< ng/ml
< ng/ml
< ng/ml

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

20. 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

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

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

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