WEEK 9 BENIGN PROSTATIC HYPERPLASIA

Question 1

What are the obstructive symptoms of BPH?

Answer 1

Obstructive=reduced bladder emptying

• Inability to empty bladder
• Decreased force of stream, hesitation, dribbling, straining

Question 2

What are the irritative symptoms of BPH?

Answer 2

Irritative=hypertrophy of bladder muscle due to long-standing obstruction

• Failure to store urine until bladder is full
• Bladder contracts with small amount of urine
• Frequency and urgency, nocturia

Question 3

Complications of BPH include…

Answer 3

• Renal failure
• Urinary tract infection
• Acute refractory urinary retention
• Overflow urinary incontinence
• Bladder stones
• Large bladder diverticuli
• Recurrent gross hematuria

Question 4

Diagnosing BPH involves…

Answer 4

Question 5

Treatment goals for BPH:

Answer 5

• Slow disease progression
• Prevent disease complications and reduce need for surgical intervention
• Avoid/minimize adverse effects
• Provide economical therapy
• Maintain/improve quality of life

Question 6

What is an option for BPH management with and enlarged prostate is present or for PSA greater than 1.5 ng/mL?

Answer 6

5 alpha-reductase inhibitors are an option for BPH management when PSA is greater than 1.5 ng/mL. Finasteride is given in doses of 5 mg by mouth daily, with or without food. No dosage adjustment is needed for renal dysfunction.

5 alpha-reductase inhibitors are a good 1st choice for the symptomatic patient with a significantly enlarged prostate (>30 to 40g by ultrasound), particularly if the cardiovascular effects of the alpha1-adrenergic antagonists are poorly tolerated. Combination therapy is often used for significantly enlarged prostate, and dysfunction is present with BPH, combination therapy with a phosphodiesterase inhibitor may be warranted.

Question 7

What is the mechanism of action for alpha1 antagonists in the treatment of BPH?

Answer 7

Selective alpha1 antagonists includse doxazosin (Cardura), prozosin (Minipress), terazosin (Hytrin), tamsulosin (Flomax), alfuzosin (UroXatral), and silodosin (Rapaflo).
MOA: block postsynaptic alpha1 receptors in the vasculature, resulting in a decrease in both arterial and venous vasoconstriction.

Orthostatic hypotension may result from action on receptors in venous smooth muscle. Reflex tachycardia may result from compensatory mechanisms, but is minimal. Chronic use of alpha1 antagonists may result in compensatory increases in blood volume but at a fairly low rate of incidence. Tamsulosin, silodosin, and alfuzosin have not been approved for the treatment of HTN.

Question 8

What are all of the relevant precautions for the use of alpha antagonists?

Answer 8

• ADVERSE EFFECTS: dizziness, hypotension, syncope, asthenia, headache, edema, dyspnea, fatigue/somnolence, URI/nasal congestion, abnormal ejaculation, intraoperative floppy iris syndrome
• Not recommended (esp. in elderly)

Question 9

Management of BPH based on AUA-S1 score and symptoms

Answer 9

Question 10

BPH treatment for Mild symptoms:

Answer 10

Mild Symptoms =

Watchful waiting or aplha adrenergic antagonis if bothersome (AUA-S1 score >8)

Question 11

BPH Treatment for Moderate symptoms:

• alpha adrenergic antagonist
• concomitant ED=alpha adrenergic antagonist, PDE5 inhibitor or both
• large prostate=5-alpha reductase inhibitor +/- alpha adrenergic anatagonist
• Predominant irritative voiding symptoms= alpha adrenergic antagonist + anticholinergic agent

Answer 11

Moderate symptoms:

Question 12

Severe BPH symptoms treatment:

Answer 12

Severe symptoms (complications of BPH)= surgery after urology referral

Question 13

Relevant precautions for the use of alpha5- reductase inhibitors:

Answer 13

• Adverse effects: ejaculation disorder, decreased libido, gynecomastia, orthostatic hypotension, dizziness
• Warnings:
  
  • Pregnancy category X
  • Potential increased risk for prostate cancer
    
    • Monitor PSA concentrations (may decrease by ~50% in 6 months)
  • Should not donate blood while on these agents