BPH – From Diagnosis To Treatment
Strategies in GP Practice
Kashifuddin Qayoom Soomro
Assistant Professor
Department of Urology
Liaquat University of Medical & Health Sciences
Jamshoro
BPH and prevalence
n
n
The most common benign tumor in men.
Half of all men over the age of 60 will develop
an enlarged prostate
By the time men reach their 70’s and 80’s, 80%
will experience urinary symptoms
BPH is a very frequent condition
in ageing men
Prevalence of BPH
90%
50%
20%
0%
< 30 years
41-50 years
51-60 years
> 80 years
What causes BPH?
n
BPH is part of the natural aging
process, like getting gray hair or
wearing glasses
BPH cannot be prevented
n
BPH can be treated
The lower urinary tract
symptoms (LUTS)
BPH
Bladder Outlet
Obstruction (BOO)
Impaired detrusor
contractility
Involuntary
bladder
contraction
• Voiding symptoms
- hesitancy
- weak stream
- prolonged voiding
- post voiding dribbling
- feeling of incomplete emptying
• Decreased flow rates
• Post void residual urine
• Storage symptoms
- urge
- frequency
- nocturia
- urge incontinence
BPH/LUTS is largely
undertreated
Percentage of men who receive medical
treatment for their LUTS by LUTS severity
100
80
60
48
45
34
40
26
19
20
11
7
4
2
Age
ve
re
e
Se
ra
t
ild
M
M
50 - 59
od
e
M
er
N
ev
ve
re
Se
ra
te
ild
od
e
M
er
N
ev
ve
re
e
Se
ra
t
ild
od
e
M
M
N
ev
LUTS
er
0
60 - 69
Rosen et al. Eur Urol 2003; 44: 637- 49
70 - 79
The Diagnosis
of BPH
The patient’s initial
evaluation
The basic evalution should be done on every
patient presenting to a health care provider with
LUTS:
 Medical history
 Assessment of symptoms
and bother
 Physical examination (DRE)
 Urinalysis
 Serum Prostate-Specific Antigen
(PSA)*
 Frequency-Volume Chart (to differentiate
between nocturia and polyuria)
*not in all patients
The medical history of the
patient

Nature and duration of LUTS

Previous surgical procedures

General health issues, sexual
function history

Medications currently taken by
the patient

The patient’s fitness for possible
surgical procedures or other
treatments
The International Prostate
Symptom Score (IPSS)

The I-PSS is based on the answers to 7 questions
concerning urinary symptoms.

Each question is assigned points from 0 to 5 indicating
increasing severity.

The total score can therefore range from 0 to 35
(asymptomatic to severely symptomatic).
Mild
Moderate
Severe
0-7
8-19
20-35
The International Prostate
Symptom Score (1)
Not at all
Less than
1 time in 5
Less than
half in the
time
About
half the
time
More than
half the
time
Almost
always
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
Patient name:
Date
1. Incomplete emptying
Over the past month, how often
have you had a sensation of not
emptying your bladder completely
after you finish urinating?
2. Frequency
Over the past month, how often
have you had to urinate again less
than two hours after you finished
urinating?
3. Intermittency
Over the past month, how often
have you found you stopped and
started again several times when
you urinated?
The International Prostate
Symptom Score (2)
Patient name:
Date
Not at all
Less than
1 time in 5
Less than
half in the
time
About
half the
time
More than
half the
time
Almost
always
0
1
2
3
4
5
0
1
2
3
4
5
Over the past month, how often have
you had to push or strain to begin to
urinate?
0
1
2
3
4
5
7. Nocturia
0
1
2
3
4
5
4. Urgency
Over the past month, how often have you
found it difficult to postpone urination?
5. Weak stream
Over the pas month, how often have
you had a weak urinary
stream?
6. Straining
Over the past month, how many times
did you most typically get up to urinate
from the time you went to bed until the
time you got up in the morning?
The bother score (IPSS 8th
question)
Patient name:
Date
1. If you were to spend the rest
of your life with your urinary
condition just the way it is now,
how would you feel about that?
Delighted
Pleased
Mostly
satisfied
0
1
2
Mixed
about
equally
satisfied
and
dissatisfied
3
Unhappy
Terrible
4
5
BOTHER SCORE (BS) =
Disease specific quality of life
and sexual function

No recommended questionnaire in routine
practice
 Sexual function questionnaires used
exclusively in clinical trials (IIEF, DANPSSsex, BSFI, MSHQ…)
The physical examination
1. Abdominal examination
 rule out other possible urinary
or rectal conditions
2. Digital Rectal Examination
(DRE)
 fundamental method for
assessing the shape and the
volume of the prostate
Urinalysis
Standard examination for the detection of:
- Haematuria,
- Proteinuria,
- Pyuria,
4-5% of men with microscopic haematuria will be
found to have a cancer or other urological disease
within the first 3 years following the test.
Serum Prostate-Specific
Antigen (PSA)

Measurement recommended for patients with at
least 10-year life expectancy and for whom
knowledge of the presence of prostate cancer
would change management

PSA is also a proxy of prostate size but its
variability is high. Recent studies suggest that it
may be used to predict the risk of AUR and
BPH-related surgery.
Frequency - volume chart

Measurement useful when nocturia is the
predominant symptom

To identify patients with nocturnal polyuria
excessive fluid intake
BPH Treatments
Treatment objectives
1. Provide rapid and sustained
relief of symptoms.
2. Act on the course of the
disease by preventing long-term
complications.
3. Respect patients’ Quality of Life
and sexual function.
The BPH patient is basically
offered 3 treatment options:
Surgery
Watchful Waiting
Medical Treatment
Definition of watchful waiting

The patient is instructed
on behavioural techniques
to reduce symptoms
(reduction of fluid intake at
bedtime, reduction of alcohol
and caffeine consumption…).

The patient’s symptoms and
clinical course should be
monitored, usually annually.
Indications of watchful
waiting

Uncomplicated BPH

Symptoms not bothersome (usually
IPSS ≤7)

Symptoms significantly bothersome
but after being informed of various
treatment options and their consequences,
the patient chooses watchful waiting
Indications of medical
treatment

Uncomplicated BPH

Symptoms are bothersome (usually
IPSS>7) and after being informed of
various treatment options and their
consequences, the patient chooses
medical treatment
There are 2 pharmacological
classes used in BPH
1-blockers
5-reductase inhibitors
The 2 components of BOO
Static Component
Normal
Dynamic Component
Hyperplastic
Increase in
prostate bulk
Increase in
smooth muscle tone
5-reductase inhibitors act on
the static component of BOO
By inhibiting the production of DHT, they are expected to
reduce the size of the prostate.
But …
 Delayed

Need 6 to 12 months to significantly improve
LUTS
 Less

onset of action
effective than α1-blockade on LUTS
Improve IPSS of 3 to 4 points
 More
effective for enlarged prostates
(> 40g)
1-receptors are abundant in the
bladder neck, prostate and urethra
They are sparse in the bladder body
1-blockers act on the dynamic
component of BOO
1-blockers are expected to reduce the sympathetic tone of the
prostate and the urethra.
1-blockers may have local
but also systemic effects
URINARY TRACT EFFECT
Prostate
Urethra
Bladder Neck
Bladder
 Outflow
resistance
 Flow
Rates
 Voiding
Symptoms
 Residual
Urine
 Bladder
Instability
 Filling
Symptoms
SYSTEMIC EFFECT
Blood vessels
 Blood
Pressure
Postural
Hypotension
Dizziness
Uroselectivity is the capacity to
achieve more local than systemic
effects
Uroselective
(new generation)
1-blockers mainly
effective on the lower
urinary tract
Non-uroselective
(old generation)
1-blockers primarily
developed for the
treatment of
hypertension
New generation (uroselective)
1-blockers
Terazosin (HYTRIN)
Doxazosin
Alfuzosin
Tamsulosin
Recent molecules
Few cardiovascular & CNS
side effects
Benefits of 1-blockers in BPH

Rapid onset of action



From the first dose on peak flow rate for
terazosin ( Hytrin ), alfuzosin1 and tamsulosin2,
From the first days on LUTS
Best monotherapy for relief of LUTS3

Improvement of IPSS of 4 to 6 points

Effective irrespective of prostate size
 Improve quality of life and respect sexual
function
1Marks
et al. Urology 2003, 62, 888-893
Urology 1998, 51, 892-900
3AUA Practice Guidelines Committee, J.Urol 2003, 170, 530-547
2Lepor
Benefits of 1-blockers in BPH

Facilitate catheter removal with return to normal
voiding in men with AUR1

Reduce BPH progression:


1McNeill
Terazosin ( Hytrin ), Alfuzosin and doxazosin do not
prevent the occurrence of AUR2-3.
However, Terazosin ( Hytrin ) alfuzosin and
doxazosin significantly reduce deterioration of LUTS
compared with placebo2-3.
et al. Urology 2005, 65, 83-90
et al. NEJM 2003, 349, 2387-98
3Roehrborn et al., BJU Int 2006, 97, 734-741
2McConnell
Complicated BPH
 Bladder

stones
Recurrent haematuria
 Acute
Urinary Retentions
 Damage
 Urinary
to kidneys
tract infections
Surgical Treatments






Open prostatectomy
Transurethral Resection of the Prostate (TURP)
Transurethral Incision of the Prostate (TUIP)
Transurethral Microwave Thermotherapy
(TUMT)
Transurethral vaporization of the prostate
(TUVP)
Transurethral needle ablation of the prostate
(TUNA)
CONCLUSION
 Every male > 50 yrs of age should be
evaluated



To exclude possibility of Ca prostate
To exclude complication resulting from
BPH
To improve the quality of life of patients
having LUTS with medical therapy
Thanks