PROSTATE DISEASE
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Benign prostatic hyperplasia (BPH) is a very common condition and the most common cause of lower urinary tract
symptoms (LUTS) in men
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LUTS can be divided into obstructive (hesitancy, weakened stream, straining, incomplete emptying, urinary retention,
overflow incontinence) and irritative (frequency, urgency, nocturia) symptoms
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AUA estimates that 90% of men aged 45 to 80 years experience some form of LUTS
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Prevalence of BPH and the reported severity of LUTS both increase with age
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From an anatomic perspective, BPH generally begins at the central transition zone of the prostate, running adjacent to the
course of the prostatic urethra
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LUTS occur as a combined result of direct bladder outlet obstruction with increased resistance to urinary flow and
increased smooth muscle tone within the prostate gland. In time, detrusor muscle dysfunction can also develop
EVALUATION
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A thorough history should be taken to assess for any “red flag” symptoms (fever, hematuria, weight loss), recent urinary tract infection, and recent or
distant pelvic trauma or surgery, and to assess for the presence of other causes
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BPH symptoms can be classified as mild, moderate, or severe by using the AUA Symptom Index (AUA-SI), a validated clinical survey that quantifies
and stratifies patients based on their symptoms
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A digital rectal examination may be performed to assess for prostate size, symmetry, and nodularity
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Physical examination should also assess for bladder distention, reduction in perineal sensation, and adequacy of rectal
tone
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Although recommended by the AUA, digital rectal examination has a low sensitivity (59%) and low positive predictive value
(28%) for BPH and is subject to significant interexaminer variability
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AUA recommends obtaining a serum prostate-specific antigen (PSA) level in all patients with LUTS and a life expectancy
greater than 10 years. An elevated PSA level commonly occurs in BPH, and the finding is less specific for prostate cancer
in this population
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The decision to obtain a serum PSA level should be individualized to each patient, after an in-depth discussion of risks and benefits
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Urinalysis is recommended for all patients to assess for the presence of infection and hematuria
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A postvoid residual study is reserved for patients with a history suggesting urinary retention, whereas a uroflow/urodynamic
study can be used in ambiguous cases
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Studies, such as serum creatinine measurement, ultrasonography, and endoscopy, are not recommended in the absence of other symptoms
TREATMENT
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Guided by the severity of symptoms (by using the AUA-SI) and is aimed at improving quality of life
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The AUA suggests that if a patient has mild symptoms (AUA-SI score of 0 to 7) or moderate (AUA-SI score of 8 to 19) to
severe (AUA-SI score of 20 to 35) symptoms that are not bothersome, no specific treatment is required beyond
reassurance. Conversely, if a patient has bothersome moderate to severe symptoms, treatment should be considered
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Treatment options include lifestyle modifications, medications, and surgical interventions
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Lifestyle modifications should be offered to patients as first-line therapy with or without medications. Helpful measures may include weight loss,
decreasing nocturnal fluid intake, and timed voiding. The diuretic effects of caffeine and alcohol may worsen symptoms, and intake should be
limited
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Medical therapies for BPH should be offered in a systematic approach. The most commonly used classes of medications
for BPH include α-blockers, 5α-reductase inhibitors, and anticholinergic agents
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α-Blockers (tamsulosin, terazosin, doxazosin, alfuzosin, silodosin) work by blocking α-receptors in the prostatic urethra and bladder neck, thereby
decreasing smooth muscle tone within the gland and leading to reduction in LUTS
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Effects are usually reported in approximately 4 weeks, with studies demonstrating roughly equal efficacy among different α-blockers
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Patients should be counseled on potential side effects, including hypotension (especially with terazosin and doxazosin), orthostasis, and sexual
dysfunction
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In patients taking a phosphodiesterase-5 inhibitor for erectile dysfunction, α-blockers can lead to significant hypotension
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Tadalafil, a phosphodiesterase-5 inhibitor useful in the treatment of erectile dysfunction, improves LUTS and may be a reasonable option in patients
with concomitant BPH and erectile dysfunction.
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5α-Reductase inhibitors (finasteride and dutasteride) block the conversion of testosterone to dihydrotestosterone; this leads to a reduction in
prostatic size and thus improvement in LUTS
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The AUA recommends the addition of 5α-reductase inhibitors in patients with BPH refractory to α-blocker monotherapy who have an
enlarged prostate on examination
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Unlike α-blockers, which work relatively quickly, 5α-reductase inhibitors take approximately 6 months to improve symptoms
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Side effects include erectile and ejaculatory dysfunction and decreased libido. The reduction in prostatic size causes a reduction in serum PSA levels
(up to 50%); knowledge of this effect is important for patients undergoing routine monitoring of serum PSA levels
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Anticholinergic agents (oxybutynin, tolterodine, solifenacin) can be offered to patients with significant irritative symptoms
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Studies have shown that combination anticholinergic and α-blocker therapy is more effective than α-blocker monotherapy.
Patients should be counseled on potential side effects, including urinary retention, constipation, dry mouth, and dry eyes
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Various herbs, supplements (including saw palmetto), and alternative therapies (such as acupuncture) have been studied
to assess for efficacy in improving LUTS associated with BPH but are not recommended because of a lack of clear benefit
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Referral to a urologist for a potential surgical intervention (transurethral resection of the prostate, transurethral needle
ablation, transurethral vaporization, transurethral microwave thermotherapy, and various laser techniques) is warranted in
patients with medically refractory symptoms or with BPH-mediated complications
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BPH-related complications include recurrent urinary tract infection, bladder stone, obstructive nephropathy, persistent hematuria, and urinary
retention
PROSTATITIS
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Prostatitis encompasses several disparate disorders, including acute bacterial prostatitis, chronic bacterial prostatitis,
chronic pelvic pain syndrome, and asymptomatic prostatitis
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Acute bacterial prostatitis is characterized by irritative voiding symptoms; perineal pain; systemic symptoms of fever, chills, myalgia, and malaise;
and potentially features of sepsis
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Chronic bacterial prostatitis causes irritative voiding symptoms and perineal pain, but patients are not systemically ill
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Bacterial prostatitis is most commonly caused by Escherichia
coli, Klebsiella, Proteus, Pseudomonas, Enterococci, Neisseria, and Chlamydia
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Chronic pelvic pain syndrome is associated with chronic pelvic pain and intermittent voiding symptoms without evidence of infection
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Chronic pelvic pain syndrome is associated with chronic pelvic pain and intermittent voiding symptoms without evidence of
infection
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When encountering a patient with signs and symptoms concerning for prostatitis, it is imperative to exclude other causes, including testicular,
epididymal, urethral, rectal, or urinary tract conditions
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Evaluation should include examination of the prostate, which often is tender, enlarged, boggy, and edematous in acute bacterial prostatitis; mild
tenderness or a normal prostate examination may be present with the other causes of prostatitis
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Additional diagnostic measures should include a urinalysis with Gram stain and culture, as well as expressed prostatic secretion culture (by prostatic
massage)
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However, prostatic massage is contraindicated in acute bacterial prostatitis, given concern for possible abscess, bacteremia, and sepsis. Tests such
as semen analysis, PSA level, prostatic imaging (ultrasonography or CT), and prostate biopsy are not routinely performed.
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In acute bacterial prostatitis, mild to moderately ill patients are treated with an antimicrobial agent with good prostate tissue penetration, such as
ciprofloxacin or trimethoprim-sulfamethoxazole, for approximately 6 weeks. In severely ill patients, hospitalization and parenteral antibiotics may be
necessary.
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Chronic bacterial prostatitis is treated similarly with an antimicrobial agent for approximately 6 weeks. First-line therapy is a
fluoroquinolone or trimethoprim-sulfamethoxazole; second-line therapy is doxycycline or azithromycin. Some patients might
require a prolonged antibiotic course of up to 12 weeks to minimize the risk for recurrent episodes
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Chronic pelvic pain syndrome is best managed with a multimodal approach that includes an antimicrobial agent (6 weeks' duration) and an αblocker such as tamsulosin. Other treatment options include 5α-reductase inhibitors, anti-inflammatory analgesics, neuromodulating agents
(pregabalin, gabapentin, nortriptyline), and nonpharmacologic strategies such as cognitive behavioral therapy, biofeedback therapy, and physical
therapy. Asymptomatic prostatitis requires no specific treatment
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