Overview of BPH management, LUTS management

understanding about prostate enlargement and various management options . laser prostatectomy and Bipolar TURP are gold standard. newer modalities like urolift covered in next ppt

1. BPH Management- Recent update.
Dr Y P SINGH RANA
CONSULTANT UROLOGY – BLK
Hospital

2. Moderate to severe Lower Urinary Tract Symptoms (LUTS)
occur in 25% of men over 50 years, and the incidence rises
with age
Approximately 90% of men will develop histological
evidence of BPH by 80 years of age
Increasing because:
Men are living longer
Proportion of Men over 50 years will increase
Men are better informed about health matters

3. Increasing age incidence

4. Bph
An anatomic entity
producing Bladder
Outlet obstruction

5. A pathological entity
Dynamic component
Static
component.

6. Prostatism= LUTS

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Frequency
Urgency/ urge incontinence
nocturia
Reduced stream
Hesitancy
Intermittency
Irritative symptoms
Obstructive symptoms
Bothersome

8. International Prostatic Symptoms
Score
Questions Score 1-5
1 frequency
2 urgency
3 Weak stream
4 Incomplete
void
5 hesitancy
6 Straining to
void
7 nocturia
8 Quality of
life

10. Differential diagnosis
Ca prostate
Stricture urethra
Meatal stenosis
Ca bladder
Urinary tract infection

11. Investigations
CBC
Urine RE and culture
USG KUB region with PVR
S Creatinine
Blood sugar
Serum PSA

12. Uroflowmetry
voided vol
Qmax
Voiding time

13. Urodynamic study
Neurological disease Parkinsonism, CVA,
Dementia
Previously operated
Discrepancy of size to symptoms
Bladder contractility
Outflow resistance

14. Indications for Surgery
•Recurrent UTI
•Recurrent Haematuria
•Refractory Retention
•Bladder Calculus
•Decompensation of Bladder / Upper tracts

15. Life style modifications
Moderation fluids, tea, alcohol
Avoid constipation
Reduce diuretics

16. Classes of drugs
Alpha blockers
5 alpha reductase inhibitors
Antimuscarinic drugs
PD5 inhibitors
Phytotherapy

18. Alpha Blockers
•Alpha 1 A commonest receptor
•Relieves dynamic component of
obstruction
•Improve symptom score 30-40%
•Improve urine flows 16-25 %

19. Alpha Blockers
Doxazosin
Terazosin
Prazosin
Tamsulosin
(greater 1 A
selectivity
alfuzosinSilodosin
Highest 1
A
selectivity
Naftopidil
Dose titrationYes 0.4 mg od 10 mg od8 mg 50 mg
Hypotension 3-4% 3% 1% 0.6% 16%
Anejaculation 1% 10% 1-3% 28% 10%

20. SILODOSIN
•Highest affinity for alpha 1a adrenergic
receptor.
•Approved by FDA in 2008 and showed rapid
increase in urine flow.
•Causes practically no orthostatic hypotension

21. IR
IFIS- Intraoperative Floppy Iris
Syndrome
•Small pupil ,not dilating,
flaccid iris
•Unopposed parasympathetic iris constriction,
loss of tone
•Increased difficulty in cataract surgery
•Stop Tamsulosin 10days prior to cataract
surgery

22. 5 Alpha Reductase Inhibitors(5ARI)
•Finasteride 5mg od
Type 2
•Dutasteride 0.5 mg od
Type 1&2

24. 5ARIs
•Reduces prostate size 18-20%
•Acts on static component
•Takes 3 mths to full effects
•Reduces PSA by 50%
•Possible role in Ca Prostate prevention
•Reduces microvessel density: lesser
haematuria

25. PCPT PROSTATE CANCER PREVENTION
TRIAL
•18882 MEN , 55 yr or more , normal rectal exam, PSA<3,
placebo or Finasteride , 7 yr follow up and biopsy
•Cancer in 18% vs 24% p=0.001
•NEJM 2003 IAN THOMSPSON

26. Combination of alpha blocker and
5 ARI
•MTOPS trial
•3047 men treated with placebo / Doxazosin/
Finasteride or combination
•Prostate size> 37 g, symptoms IPSS 17
Symptom progression > 4, retention, surgery

27. Cumulative Incidence of Progression
(N Engl J Med 2003: 349 (25): 2387-97)

28. MTOPS conclusions
•Combination works better than single drug
•50% risk reduction in retention
•50% risk reduction in surgery.

29. Anti Muscarinics
•Irritative symptoms / Incontinence common
•Quality of life severely hampered
•Bladder specific anti cholinergics to counter
overactivity
•Risk of retention low

30. Antimuscarinics –therapeutic
window

31. Anti muscarinics
•Main receptors are M3 and M2
•Avoid in patients with low flows and high
PVR> 200 ml or prior retenton-Risk of
retention
oxybutyninTolterodi
ne
SolifenacinDarfenacinTrospium
2mg 5/10mg 7.5/15 mg60mg

32. PD5 inhibitors
•Many patients have concurrent ED
•PD5 expressed in prostate/bladder neck ,
pelvic vasculature
•Relax muscles/ relax vessels and improve
oxygenation, reduce inflammation
•Beneficial effects when combined with Alpha
blockers

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Drugs in bph
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5 Alpha reductase
Inhbitors
PD 5 Inhitors
Antimuscarinics
Alpha blockers

35. Management of Retention
•Acute retention is painful
Precipitating factor: Spinal anaesthesia/ high fluid intake etc . Recurrence
9%
Spontaneous retention Recurrent 15 %
•Chronic retention painless
•Pass catheter.
•Do trial of catheter free void after 72 hr with alpha blockers
•No role of trial clamping before catheter removal
•Decompression haematuria – common , resolves
spontaneously
•Post obstructive Diuresis , reduction in Serum Na/ K common

36. Urinary Tract Infections
•Complicated UTI due to BPH
•Treat underlying BPH – Surgery/ Medicines
•Suppressive antibiotics
•CIC – If PVR are high

37. Surgical Therapies
•TURP still the gold standard therapy, with
which all other therapies must be
considered
•Laser prostatectomy .
–expensive to set up
–Reduced blood loss with KTP and Diode.
•Open Prostatectomy rarely required

38. Conclusions
•Document the IPSS score
•LUTS ≠ BPH
•Indications for surgery
•Life style modifications
•Combination drug therapy
•Treat retention with drugs+ Catheterisation

39. Thank you for your attention
I bet he takes
SILDURA

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