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Canadian Undergraduate Urology Curriculum ( CanUUC ): Prostate Diseases

Dive into the CanUUC Prostate 1 curriculum to learn about Lower Urinary Tract Symptoms (LUTS) and Benign Prostate Hyperplasia (BPH) including pathophysiology, symptoms, treatments, and evaluation methods. Explore the complexities of prostate diseases in an educational format.

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Canadian Undergraduate Urology Curriculum ( CanUUC ): Prostate Diseases

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  1. Canadian Undergraduate Urology Curriculum (CanUUC):Prostate Diseases Last reviewed May 2017

  2. Prostate 1: LUTS/Benign Prostate Hyperplasia

  3. Objectives • Describe the lower urinary tract symptoms (LUTS) found in men with BPH. • Outline the investigations required when evaluating a man with LUTS. • Describe the medical treatments of BPH. • Describe the indications for surgical treatment of BPH.

  4. Benign Prostatic Hyperplasia • Commonly associated with “voiding” & urinary “storage” symptoms • Epidemiology • Extremely common with 70% of men in their 70’s describing voiding symptoms

  5. Benign Prostatic Hyperplasia: Pathophysiology • Pathophysiology • Prostate volume increases from puberty • Androgen dependent • Symptoms correlate with gland size, but not strongly • Static compression of the urethra • Glandular volume • Dynamic compression of the urethra • Smooth muscle component of prostate stroma Hypertrophied detrusor muscle Obstructed urinary flow

  6. Lower Urinary Tract Symptoms (LUTS) • Storage Symptoms • Frequency • Urgency ± urge incontinence • Nocturia • Voiding Symptoms • Hesitency • Decreased stream • Straining to void • Incomplete emptying • Urinary retention • Overflow incontinence *LUTS does not equate to BPH but BPH is the most common cause of LUTS*

  7. Differential Diagnosis of LUTS • Multiple problems can co-exist • Pre-Prostatic Causes • Stones/Tumors • Infections/inflammatory conditions • Neurogenic Bladder (spinal cord injuries, MS, Diabetes, etc) • Atonic Bladder /Overactive Bladder • Polyuria/Polydypsia • Prostatic Causes • BPH • Prostatitis • Prostate Cancer (advanced) • Post-Prostatic Causes • Urethral Stricture • Meatal Stenosis

  8. Evaluation:Medical History Medical History • Should focus on: • Urinary tract symptoms • UTI, Hematuria • Previous surgery • Family history of prostate carcinoma • Co-morbidities/general health issues • Medications (Anti-cholinergics & sympathomimetics) • Voiding diary (optional)

  9. Evaluation:Physical Examination Physical Examination • Complete exam including: • Abdomen (assess bladder) • External genitalia • Focused neurological exam • Digital Rectal Examination (DRE) • (Assess for concurrent disease)

  10. BPH:Recommended Investigations • Urinalysis and culture • Prostate Specific Antigen (PSA)(if appropriate) • International Prostate Symptom Index (or AUA symptom index) • Serum Creatinine (optional)

  11. American Urological Association Symptom Index (AUA-SI) Incomplete bladder emptying Frequency Intermittency Urgency Weak stream Straining Nocturia AUA Practice Guidelines Committee. J Urol. 2003;170(2 pt 1):530537. Barry MJ et al. J Urol. 1992;148:15491557.

  12. LUTS:Optional Investigations • Cystoscopy (only if): • If urinalysis abnormal (hematuria or pyuria) • Patient <50 years old • Renal Ultrasound (only if): • If serum Cr elevated • PVR urine/Uroflow (optional) • Urodynamic’s (if) • Patient <50 years old • Atypical symptoms or neurologic disease • Incontinence (male)

  13. LUTS:Treatment Options • Lifestyle Measures • Watchful Waiting • Medical Management • Alpha blockers • 5-alpha reductase inhibitors (5 ARI’s) • PDE5 inhibitors (Tadalafil 5mg poqDay) • Surgical Management

  14. 1. Treatment Options:Lifestyle Measures • Fluid modification • Reduce fluid intake in the evening • Avoid caffeine, alcohol • Timed voiding • Regular timed voiding of the bladder • Modify medications • I.e: change time of dosing diuretics • Avoid cold remedies (anti-histamines) • Avoid anti-cholinergics • Avoid alpha-agonists (i.e. decongestants)

  15. Treatment Options:Herbal Supplements Herbal:Commonly available OTC supplements • Saw palmetto extract (Serenoarepens) (Recent NEJM Paper cited no proven benefit) • Pumpkin seed (no evidence) • Pygeumafricanum (African Plum) Mineral: • Zinc (however, no proven benefit) • Wilt TJ, et al. JAMA. 1998;280:1604-9; • Barry MJ. BMJ. 2001;323:1042-6.

  16. 2. Treatment Options:Watchful Waiting Watchful Waiting: • Patient monitored by physician without active intervention for LUTS • Safe in patients with mild, stable symptoms • Intervene when symptoms worsen or complications arise such as acute retention, recurrent hematuria, recurrent UTI, hydronephrosis, bladder calculi

  17. 3a. Medical Treatment: Long-acting Non-selective 1-blockers • The prostate has a muscular “dynamic” component (centrally) • These fibers are alpha-receptor mediated

  18. 3a. Medical Treatment: Long-acting Non-selective 1-blockers • Dosage is increased in a stepwise fashion at weekly intervals • Does not affect PSA • Acts to relax prostatic/bladder neck smooth muscle (& vascular smooth muscle - non selective) • Doxazosin (Cardura) • Dosage: 1-2 mg qDay, titrate up to 4-8 mg OD • Terazosin (Hytrin) • Dosage: 1 mg OD, titrate up to 2, 5, or 10 mg • Not usually first line anymore

  19. 3a. Medical Management:Long-acting Selective 1A-blockers Long-acting selective 1-blockers • Specifically relaxes the smooth muscle of the prostate and bladder neck • Does not interfere with bladder contractility • Does not affect PSA • Alfuzosin (Xatral) • Dosage: 10 mg qDay • Tamsulosin(Flomax) • Dosage: 0.4 mg qDay • Silodosin (Rapaflo) • Dosage: 8mg qDay

  20. 1-Blockers:Side Effects • 5 known side effects of alpha blockade for LUTS • Asthenia • Hypotension • Retrograde ejaculation • Dizziness • Flu-like syndrome

  21. 3b. Medical Management: The 5--reductase Inhibitors 5--reductase inhibitors: • Regulate androgen available to prostate by blocking conversion of testosterone to dihydrotestosterone (DHT) • Slow the rate of prostate enlargement • Reduce prostate volume and relives “static” compression by BPH • Reduce PSA by ~50% • Takes 3-6 months to exert clinical effect

  22. 5--reductase Inhibitors • Men with larger prostates (> 40 g) respond most favorably • Finasteride(Proscar) • Dosage: 5 mg OD – type II inhibitor • Dutasteride(Avodart) • Dosage: 0.5 mg OD – type I and II inhibitor

  23. 5--reductase Inhibitors:Side Effects *percentages reflect upper estimates of incidence

  24. 3c. Medical Management: Daily PDE5 Inhibitor Tadaladfil 5mg qDay: • Improvesmale LUTS • Exact mechanism unknown • Helps concurrent erectile dysfunction • May potentiate hypotension in men taking concurrent alpha-blockers

  25. 4. LUTS:Indications for Surgery • Bothersome symptoms despite treatment • BPH-related complications • Urinary Retention (inability to void) • Bladder calculi • Recurrent UTI • Recurrent hematuria from the prostate • Upper tract dysfunction (hydronephrosis, renal dysfunction) • Surgical approach will depend on: • Patient’s prostate size • Surgeon’s judgment • Patient’s co-morbidities

  26. BPH Surgery:Transurethral Resection of Prostate (TURP) is the Most Common Surgery for BPH • Transurethral resection of the prostate (TURP) • Standard of care • Uses electrosurgeryto “core” out the obstructive tissue

  27. LUTS:Surgical Techniques TURP - Transurethral Resection of Prostate • Gold standard for surgical treatment of BPH if prostate has moderate size Minimally invasive surgeries • Numerous laser vapourization techniques Open prostatectomyto remove the central/transtion zone when prostate is very large (>100cc)

  28. Complications: TURP • Retrograde ejaculation (very common>90%) • Incontinence (1-2%) • Erectile Dysfunction (rare) • Bladder neck Contracture/Urethral Stricture (1-10%) • Bleeding (~5% need a transfusion) • Risks of any Operation

  29. Treatment of BPH:Summary • Watchful Waiting • Patients with mild symptoms • Alpha Blocker • Relaxes prostatic smooth muscle • Rapid relief of symptoms (within 2 weeks) • May not address eventual progression • 5--reductase inhibitor • Decreases prostate volume • “Slower” acting (3-6 months) • May reduce risk of progression • More suitable for larger prostates • Combination Therapy

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