1 / 42

BPH Diagnosis and Medical Treatment

BPH Diagnosis and Medical Treatment. BPH. The most common disease of aging men Present in majority of men Prevalence : 60yr : 50%↑ 85yr : 90% Wide variance in symptoms Large prostate does not equal voiding problems. LUTS. Morbidity & Complication of BPH Mortality of BPH : Rare

sally
Download Presentation

BPH Diagnosis and Medical Treatment

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. BPHDiagnosis and Medical Treatment

  2. BPH • The most common disease of aging men • Present in majority of men • Prevalence : 60yr : 50%↑ 85yr : 90% • Wide variance in symptoms • Large prostate does not equal voiding problems

  3. LUTS • Morbidity & Complication of BPH • Mortality of BPH : Rare • LUTS : Bothersome Highly variable • Treatment : Patient’s perception Degree of interfering life style

  4. Definitions and Terminology • BPH : Stromal and epithelial hyperplasia in periuretheral zone • LUTS : Lower urinary tract symptoms • The relationship of BPH & LUTS : Complex • LUTS or LUTS suggestive of BPH >> prostatism • BPH : Bothersome LUTS by histological BPH or increased tone of the prostate

  5. LUTS • Irritative versus Obstructive • Irritative • Frequency/urgency/nocturia • Obstructed • Slow stream/stranguria/start-stop • Difficult to distinguish by history alone since symptoms overlap

  6. Initial Evaluation • History • DRE & Focused PE • UA • PSA in select patients AUA/IPSS Sx Index, Bother

  7. Medical History • Surgery, general health • Voiding History: polyuria, stranguria, frequency, urgency post void dribbling • Voiding diary (nocturia) • Urinary Infections :culture • Incontinence

  8. Physical Examination • DRE • Neurologic exam • Mental status • Ambulatory status • Neuromuscular function • Anal sphincter tone

  9. Urinalysis • Bladder cancer, CIS • UTI, Urethral stricture • Urethral, bladder stones

  10. PSA • Screening for cancer • 10 year life expectancy and for whom the presence of cancer would change management One predictor of natural Hx of BPH

  11. Optional Initial Test • Urine Cytology : Bladder Ca, CIS • Predominantly irritative Sx • Smoking or other risk factors • Serum Creatinine : Not recommended • Renal insufficiency : 1%↓ • Not more common than general population • Non BPH cause as diabetic nephropathy

  12. Symptom Assessment • Sx alter QOL • Sx quantification • Severity of disease • Response of therapy • Sx progression • 0~7 : mild • 8~19 : moderate • 20~35 : severe • Not a replacement for personal discussion of Sx with the patient

  13. Symptom Assessment • IPSS : Recommended • Other validated assessment : optional • Frequency and severity of LUTS • Bother score • Interference with daily activities • Urinary incontinence • Sexual function • Health related – QOL • ICS Questionnaire, DPSS, BPH impact index, IPSS QOL, Sexual function Questionnaire

  14. QOL

  15. Optional Diagnostic Test • Uroflometry measures rate of urine flow • Not a first line test • Post-void residual urine (PVR) useful tool for evaluation and treatment • Non-prostatic case of Sx • Selection of invasive Tx • Prior failed BPH Tx • Quantitative method to diagnose and follow result of treatment

  16. Qmax : rate of urine flow • Predict the response to surgery • Predict the natural Hx of BPH Advantages • LUTS with Normal Qmax : non prostatic cause • Qmax < 10ml/sec : obstruction Disadvantages • Sx response is not dependent on Qmax • Test / retest variability, lack of well designed study → Not feasible to establish cut-point

  17. PVR • Bladder dysfunction • Identifies favorable response to Treatment • Progression of disease • Clinical tool not a singular diagnostic test • Test / retest variability • Lack of outcome studies • No PVR cut-point Optional • Doesn’t predict the response to medical Tx • Elevated PVR without UTI, renal insufficiency, bothersome Sx - No level of RU mandates invasive Tx

  18. Optional Diagnostic Tests Who Choose Invasive Tx • Pr-flow study • Qmax > 10ml/sec & surgery considered • Prior failed surgery • Neurologic disease • Not indicated to predict response to medical Tx • Cystoscopy : Hematuria, urethral stricture r/o Bladder Ca, prior surgery • TRUS : Size & shape, selection of surgery

  19. CMG, IVP, USG of Kidney • Not recommended • Indicated in Hematuria, UTI • Renal insufficiency, stone Hx, upper tract surgery Hx

  20. Initial Management and Discussion of Treatment Options • Watchful waiting • Medical therapy – pills • Minimally invasive surgery • Surgery

  21. Treatment • Watchful waiting • Mild Symptoms • Mod or severe Symptoms without Renal insufficiency, UTI, retention • Increase water intake↓ • Decrease alcohol↓, Caffeine↓ SODA • DRE, PSA : suggests natural Hx of Sx flow rate, AUR, surgery

  22. Medical Treatment Options • Alpha-adrenergic blockers • 5 alpha-reductase inhibitors • Combination therapies • Phytotherapy

  23. Alpha-adrenergic Blockers • Opens prostatic urethra by relaxing smooth muscle in prostate • Doxazosin, terazosin, flomax, uroxatrol and rapaflo • Equal effectiveness • Differences in adverse events • LUTS secondary to BPH • Very effective in relieving symptoms of BPH

  24. Alpha-adrenergic Blockers • Side Effects: postural hypotension, retrograde ejaculation • Hypertension and cardiac risk factors LUTS – Alpha blocker only: incidence of CHF • Patients with hypertension : separate management of hypertension • May make cataract surgery difficult (floppy iris syndrome)

  25. 5 Alpha-reductase Inhibitors • Reduces prostate volume 25-28% • Reducing volume doesn’t always relieve obstruction • Symptomatic prostatic enlargement treatment helps to prevent progression of disease (AUR, surgery) • Sexual dysfunction, long-term Tx • Not appropriate for men with LUTS without prostatic enlargement

  26. Natural History of BPH • PLESS study 1. 3,040 clinical BPH patients 2. IPSS: moderate to severe 3. Qmax: <15 ml/s 4. DRE: enlarged prostate gland 5. PSA <10 ng/ml (PSA 4-9.9: negative biopsy) 6. Follow-up: 4 years

  27. Natural History of BPH • Risk of Acute Urinary Retention or Surgery

  28. Natural History of BPH • Change of Symptom Score

  29. Natural History of BPH • Change of Peak Urinary Flow Rate

  30. Surgery • Minimally Invasive (office) • Microwave • TUNA • Interstitial Laser • Surgery (operating room) • TURP • HOLAP • HOLEP

  31. Surgery • Patient selection determines type of procedure offered • Surgery very effective in properly selected patients • Majority of patients stop medications • Absolute indications • Retention • Recurrent infections • Bleeding • Stones

  32. Surgery • Absolute Indications • Retention • Repeated infection • Bladder stones • Relative indications • Worsening symptoms • Rising urine retention • Desire to stop medication

  33. Surgery • Minimally invasive surgery • Better symptom results than medication • Minimal recovery – days • Low incidence of long-term side effects • No incontinence after treatment • Higher future retreatment rates than surgery • Not effective for patients in urine retention • Excellent alternative to medication

  34. Surgery • OR based surgery • Most effective means of relieving prostate obstruction • Requires general/spinal anesthesia • Removal of prostate tissue • Variety of energies used to remove tissue • Requires catheters after treatment • Usually involves hospitalization

  35. Surgery • Indicated for urine retention • Highest side effects • Possible incontinence • Retrograde ejaculation • Best treatment outcomes • Improves flow rate • Lowers voiding symptoms

  36. Recommendations • Goal directed therapy • Most patients have a variety of treatment options • Medical management works well for most patients with minimal side effects • Modern procedures are effective and safe • Informed patient decision making : benefits, risks, costs

More Related