Benign prostatic Hyperplasia dr surya.pptx

This PowerPoint presentation (PPT) on Benign Prostatic Hyperplasia (BPH) provides a comprehensive overview of one of the most common urological conditions affecting aging men. The presentation covers the definition, etiology, pathophysiology, clinical features, diagnosis, complications, and treatment options for BPH. It also includes insights into the latest pharmacological treatments such as Alpha-1 Adrenergic Blockers, 5-Alpha Reductase Inhibitors, Combination Therapy, and Minimally Invasive Surgical Procedures.

1. PHARMACOTHERAPY OF BPH DR. SURYA K JUNIOR RESIDENT -1 DEPT OF PHARMACOLOGY KGMU,LUCKNOW

2. Benign prostatic hyperplasia (BPH) is a benign enlargement of the prostate gland . In many patients older than 50 years, the prostate gland enlarges , extending upward into the bladder and obstructing the outflow of urine by encroaching on the vesicle orifice, known as benign prostatic hyperplasia (BPH ),or hypertrophy , of the prostate . It is the most common urologic problem in male adults. About 50% of all men in their lifetime will develop BPH . Of these men, almost half of them will have bothersome lower urinary tract symptoms.

3. A MODERN VIEW OF BPH CLINICAL, ANATOMIC, AND PATHOPHYSIOLOGIC CHANGES : BPH = Benign Prostatic Hyperplasia Histologic : stromoglandular hyperplasia May be associated with- Clinical : presence of bothersome LUTS Anatomic : enlargement of the gland (BPE = Benign Prostatic Enlargement) Pathophysiologic : compression of urethra and compromise of urinary flow(BOO = Bladder Outlet Obstruction )

4. INCIDENCE: 50 % of men having evidence of BPH by age of 50years . 75 % by age of 80 years . CAUSES : Dihydrotestosterone (DHT ).

5. RISK FACTORS FOR PROSTATE GLAND ENLARGEMENT : Aging: Enlargement rare – in <age 40 yrs. moderate to severe - age 60 & 80 yrs. Family history. Ethnic background : less common in Asian men than in white and black men . Diabetes and heart disease and use of beta blockers : might increase the risk of BPH. Lifestyle :Obesity increases the risk of BPH .

6. PATHOPHYSIOLOGY :

7. CLINICAL MANIFESTATIONS : Symptoms attributable to lower urinary tract dysfunction storage ( irritative ) symptoms . emptying (obstructive) symptoms . Hesitancy & Urgency . Increased frequency of urination . Nocturia .

8. Acute urinary retention (more than 60 ml ). Recurrent UTIs Fatigue . Anorexia . Abdominal straining.

9. Nausea and vomiting . Dribbling & Sensation of incomplete emptying of the bladder. Pelvic discomfort and pain . Ultimately azotemia . Renal failure result with chronic urinary retention and large residual volumes . Blood in the urine.

10. LOWER URINARY TRACT SYMPTOMS DUE TO BPH ARE CAUSED BY THREE MAIN FACTORS: D ynamic – tone of the prostatic smooth muscle and bladder neck . S tatic – enlarging prostatic adenoma causing mechanical obstruction . C ompensatory – hypertrophy and irritability of the bladder muscle ( detrusor).

11. ASSESSMENT AND DIAGNOSTIC METHODS: History collection. Physical examination- including digital rectal examination(DRE) & neurological examine. Urinalysis to screen for hematuria and UTI . Prostate-specific antigen (PSA) level.

12. Urinary flow-rate recording and the measurement of postvoid residual (PVR) urine. Urodynamic studies . Urethrocystoscopy . Ultrasound . Complete blood studies, including clotting studies.

13. GOALS OF THERAPY: ↓ symptoms (IPSS/AUA ). ↓ bother (bother score) and ↑ QOL. ↓ prostate size or arrest further growth. ↑ Increase in peak flow rate / Relieve obstruction. Prevention of long-term outcomes/complications. Acceptable adverse events profile.

14. TREATMENT MEASURES INCLUDE THE FOLLOWING: 1 . Immediate catheterization if patient cannot void (an urologist may be consulted if an ordinary catheter cannot be inserted ). 2 . A suprapubic cystostomy is sometimes necessary . 3. "Watchful waiting" to monitor disease progression .

15. Medical Treatment:  -adrenergic blockers – DOC Dynamic component 5  -reductase inhibitors. Anatomic component Anticholinergic Therapy. Storage Sx’s

16. Alpha blockers : These medications relax bladder neck muscles and muscle fibers in the prostate, making urination easier . Selective : Alfuzosin ( Uroxatral ). Doxazosin ( Cardura). Tamsulosin (Flomax ). Terazosin ( Hytrin ). Silodosin ( Rapaflo ) usually work quickly in men with relatively small prostates . Non – selective : Prazosin

17. Comparison of - Adrenergic Blockers Agent Dosing Titration Uroselective Terazosin ( Hytrin ® ) 1 mg, 2 mg, 5 mg, 10 mg, 20 mg + NO Doxazosin (Cardura ® ) 1 mg, 2 mg, 4 mg, 8 mg, 16 mg + NO Tamsulosin (Flomax ® ) 0.4 mg, 0.8 mg +/- (for improved efficacy) YES (Relative affinity for  1A receptors over  1B ) Alfuzosin 10 mg - YES (Highly diffused in prostatic tissue vs serum)

18. Adverse effects: E jaculatory dysfunction . R etrograde ejaculation, erectile dysfunction . Nasal congestion . H ypotension , dizziness and tachycardia . Tamsulosin , have been associated with intra-operative floppy iris syndrome.

19. 5-alpha reductase inhibitors These medications shrink prostate by preventing hormonal changes that cause prostate growth . F inasteride ( Proscar ) - inhibits only type 2 isoenzymes of 5-alpha-reductase . Dutasteride (Avodart) - inhibits both the type 1 and type 2 isoenzymes of 5-alpha-reductase. - might take up to six months to be effective.

20. Adverse effects: Erectile dysfunction. Decreased libido. Decreased ejaculate and decreased semen count . These adverse effects can be irreversible and debilitating, therefore counselling is strongly recommended before prescribing .

21. Anticholinergic Therapy : Oxybutynin . Festerodine . Darifenacin . Tolterodine . Flavoxate .

22. Effective in relieving overactive bladder symptoms in patients without bladder outlet obstruction . Contraindicated in patients with LUTS associated with BPH because of concerns for developing acute urinary retention .

23. Oxybutynin - has direct antispasmodic effects on smooth muscle and anticholinergic effects. Decreases frequency of voiding . Flavoxate - relieves dysuria, urgency, frequency and pain with genito -urinary infections. Tolterodine - is competitive, Antimuscarinic anticholinergic that inhibits contraction. More selective for this area than elsewhere in the body.

24. Combination drug therapy Doctor might recommend taking an alpha blocker and a 5- alpha reductase inhibitor at the same time . Tolterodine and Tamsulosin therapy: Improved QoL Increased bladder capacity. “ Effective & safe treatment option in patients with BOO and detrusor overactivity ” .

25. Phosphodiesterase-5 inhibitors: Tadalafil (Cialis ) Used to treat erectile dysfunction, can also treat prostate enlargement. can be effective in the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia, however they are less effective than alpha blockade.

26. Tadalafil has an indication for benign prostatic hypertrophy and erectile dysfunction. Headache is a common adverse effect of phosphodiesterase- 5 inhibitors. They should be avoided in patients receiving nitrates for ischaemic heart disease.

27. SURGICAL MANAGEMENT : Minimally Invasive Therapy. Invasive Therapy.

28. MINIMALLY INVASIVE THERAPY more common as an alternative to watchful waiting and invasive treatment. Transurethral Microwave Thermotherapy. Photovaporization . Transurethral Needle Ablation. Interstitial laser coagulation (ILC). Laser Prostatectomy. Intraprostatic Urethral Stents.

29. (B) INVASIVE THERAPY Invasive treatment of symptomatic BPH involves surgery. The choice of the treatment approach depends on the size and location of the prostatic enlargement and patient factors such as age and surgical risk. 1) Transurethral Resection of the Prostate( TURP). 2) Transurethral Incision of the Prostate.

30. Transurethral Resection of the Prostate

31. PATIENT EDUCATION AND HEALTH MAINTENANCE Explain to patient not undergoing treatment the symptoms of complications of BPH urinary retention, cystitis, and increase in irritative voiding symptoms. Encourage reporting to doctors. Advise patients with BPH to avoid certain drugs that may impair voiding, particularly OTC cold medicines containing sympathomimetics such as phenylpropanolamine.

32. Tell patient postoperatively to avoid sexual intercourse, straining at stool, heavy lifting, and long periods of sitting for 6 to 8 weeks after surgery, until prostatic fossa is healed . Advise follow-up visits after treatment because urethral stricture may occur and regrowth of prostate is possible after TURP .

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