Management of BPH and Prostatitis 3.1.2 Flashcards
What are the treatment aims for BPH?
- Improving symptoms (by decreasing urinary outflow resistance)
- Reducing long-term complications
What are some treatment considerations for BPH? What is the international prostate symptom score?
- Is BPH uncomplicated and patient not bothered by symptoms –> watchful waiting an option
- Aggravating factors such as constipation
- Prostate size
- Symptoms severity
> International prostate symptom score = monitor symptoms
- Mild 0-7
- Moderate 8-19
- Severe 20-35
- Quality of life due to urinary symptoms (1 is pleased, 6 is terrible)
Why surgery for BPH? When is it preferred? What are the options?
- More effective than drug treatment
- Preferred when symptoms severe, drugs ineffecive, urinary retention
- Transsurethral resection of the prostate (TURP) - gold standard
- Open prostatectomy
- Urolift
- Minimially invasive techniques
> thermotherapy - TUMT ( transurethral microwave therapy), TUNA (trans-urethral needle ablation), laser treatment
When is drug therapy considered for BPH?
Considered when
- symptoms troublesome
- patient’s preference
- surgery contraindicated/not indicated
What are some factors influencing drug selection?
Prostate size = crucial
Symptom relief
How long does selective alpha blockers take to work (APST)? What do they do?
- Symptom improvement in 48 hours (full effect in 4-6 weeks)
- Effective regardless of prostate size
- Improve urinary flow
- Indication: symptom relief in BPH and lasts for long term/time
When is alfuzosin (more selective for prostate) CI? I?
- CI in hepatic impairment
- Metabolised by CYP3A4
When to reduce dose for silodosin?
CrCL 30-60 mL/min?
Has terazosin been discontinued?
Yas
AE for alpha-1 blockers (APST)?
First dose hypotension (prazosin more common), dizziness, headache, urinary urgency, abnormal ejaculation
Which are three alpha-1 blockers that has less BP effects and the better choice in BPH?
Alfuzosin, silodosin, tamsulosin = better choice in BPH
Which alpha blocker have to take bd?
Prazosin (shorter DOA)
Which alpha blocker has higest rate of ejucalatory abnormalities?
Silodosin
Which alpha blocker causes floppy iris syndrome during cataract surgery?
all of them but tamsulosin especially
> high selectivity therefore have catarac surgery before starting alpha blocker
What to monitor for alpha blockers?
efficacy, BP, symptoms of hypotension
When to stop treatment if no benefits for alpha blockers?
after 4-6 weeks, should work beforte this period
When are 5-alpha reductase inhibitors used? What benefits does it have in BPH?
Reserved for large prostates
> prostate greater than 30-40cm3
- can improve prostate size, rates of urinary retention, urinary flow, srugery
How long does it take for symptom improvement and full effects for 5a-reductase inhibitors?
- 6 month for symptom improvement
- 12-18 months full effects
Compare dutasteride and finasteride (5-alpha reductase inhibitors)
dutasteride = inhibit type 1 and type 2 of 5a isozymes = 90% reduction in DHT
finasteride = inibit type 1 = 70% reduction in DHT
What are AE of 5-alpha reductase inhibitors
Decreased libido, impotence, ejaculatory disorders
> decreased testosterone levels
> less common = gynaecomastia and breast tenderness
What is the half life of dutasteride and finasteride
dutasteride = 3-5 weeks
finasteride = 6 hours
Why should pregnant women or those planning to get pregnant wear gloves when handing dutasteride and finasteride?
Casuses feminisation of male foetus
Prostate specific antigen reduced by 50%, how long does it take for dutasteride and finasteride? What happens if drugs are stopped? What to do if PSA increases during treatment?
6 months of dutasteride
1 year for finasteride
- PSA returns to baseline after 6 months treatment cessation
- If PSA increases during treatment –> assess for prostate cancer
Why use combination therapy of Alpha blocker and 5a RI? How long for the maximum effect of selective alpha blocker?
Prostate greater than 30-40cm3 = 5a reductase inhibitor
Fast relief of symptoms needed = alpha blocker
Selective alpha-blocker can be stopped after 6-12 months maximum effect reached at this time
Any other options for BPH? Is any complementary medicines effective for BPH?
- Watchful waiting
- Tadalafil
- Anticholienrgic in continiuing bladder overactivity
- CAMs
Only CAMs that are likely safe and likely effective are
- Beta sitosterol
- Pygeum
How is beta-sitosterol helpful for BPH?
Improves urinary symptoms, maximum urinary flow, post-void residual urine volume
> no effect on prostate size
How is pygeum helpful for BPH?
Shown to decrease nocturia (19%)
Increase peak urine flow (23%)
Residual urine volume (24%)
Is saw palmetto an option for BPH?
Likely safe but possibly ineffective
> widely used but data conflicting
Non-pharmacological considerations for BPH?
- Avoid cold temperatures (urge to urinate), wetness
- Relax when urinating, avoid letting bladder get full
- Pelvic floor exercises
- Stress reduction
- Restrict fluid intake at bedtime
- Reduce coffee, alcohol and spicy foods
- No smoking
- Avoid anticholinergic medications (eg OTC antihistamines, can promote urinary retention)
Treatment aims for BPH?
- Symptom relief
- Cure infection
- Reduce complications
What to use for mild to moderate infection (empirical) for acute BP
Oral trimethoprim or ciprofloxacin for 2-4 weeks (AMH)
Oral trimethoprim or cefalexin for 2 weeks (eTG)
What to use for severe infection for BP (short term empirical)? What to ensure for BP ?
- IV antibiotics, fluid replacement
- Amoxicillin/ampicillin plus gentamicin (renal considerations)
- Ceftriaxone or cefotaxime (when gentamicin C/I)
Ensure: hydration, stool softener (constipation worsens pain), rest, analgesia (NSAID), paracetamol
What to use for chronic bacterial prostatitis?
> penetration of AB is less in chronic so use strong ones
Trimethoprim, norlfoxacin or ciprofloxacin for 4-6 weeks (AMH), 4 weeks (eTG)
doxycycline and option (if Ureaplsama or C.trachomatis)
What to use for chronic non-bacterial prostatitis?
- Frequent relapses, difficult to manage
- No proven treatment
> AB (as per CBG) if suspected undiagnosed bacterial infection
> Analgesia and address constipation
> Selective alpha-blockers for symptom relief
> Querrectin 500mg bd or pollen extract (cernilton)
What is quercetin? What is its role in chronic NBP?
Flavonol, belonging to the class of flavonoids
- occurs in red wine, onions, green tea, apple, berries, cababge, broccoli, cauliflower, turnips
- also found in gingko biloba, St John’s wort, american elder
In chronic NBP:
- reduces pain and improves QOL
What are some considerations for prostatitis?
- Avoid nitrofurantoin –> poor penetration for ABP
- Rarely sexually transmitted or systemic pathogens are involved in acute prostatitis
- Very rarely sexually transmitted pathogen in chronic bacterial prostatitis
- Chronic non-bacterial prostatitis: reduce stress, physiotherapy, relaxation
What to avoid during quinolone treatment?
Avoid quercetin –> reduced efficacy
