MANAGING BENIGN

PROSTATIC HYPERTROPHY

IN PRIMARY CARE

DR GEORGE G MATHEW

CONSULTANT FAMILY PHYSICIAN

FELLOW IN SEXUAL & REPRODUCTIVE HEALTH

INTRODUCTION (1)

• Part of male sexual reproductive organ

• Size of a walnut

• Functions to secrete prostatic fluid

that nourishes & protects the sperm

• Gives semen its milky-white

appearance

• Size remains consistent until

the age of 30

INTRODUCTION (2)

• BPH most common among elderly men

• size increase by 14% every year

• NOT a cancerous condition

• causes symptoms by pressing on the

urethra

INTRODUCTION ( 3 )

➢Benign prostate hypertrophy (BPH) affects

• 42% of men aged 50 – 60 years

• 70% of men aged 61 – 70 years

• 80% of men aged 70 -80 years

• 90% of men aged 81 – 90 years

➢Overlap of symptoms exist between

BPH and lower urinary tract

symptoms (LUTS)

INTRODUCTION ( 4 )

➢50% of men older than 60 years

have significant symptoms of

bladder outlet obstruction ( BOO)

affecting quality of life

• disruption of sleep

• limitation of fluid consumption

• Inability to drive more than 2 hours

• impact on social life (e.g. cinema)

INTRODUCTION ( 5 )

➢Most cases can be managed in primary care

➢Primary care doctor needs to know

• how to assess

• diagnose

• differential diagnoses

• investigate

• manage

PATHOPHYSIOLOGY (1)

• enlargement of the prostate gland from the

progressive hyperplasia of stromal &

glandular prostate cells

➢Characterised histologically by the

presence of discrete nodules in the

peri-urethral zone of the prostate

INTRODUCTION

• AB

Glandular hyperplasia with hypertrophy of

intervening fibromuscular stroma of the

gland

INTRODUCTION

• AB

INTRODUCTION

• AB

INTRODUCTION

• AB

PATHOPHYSIOLOGY (2)

• Obstruction due to

➢ direct compression of prostatic

urethra

➢Excessive tone within the smooth

muscle components of prostate

• Secondary detrusor response

• Bladder hypertrophy

• Detrusor instability

PATHOPHYSIOLOGY (3 )

➢aetiology likely endocrine basis

➢other factors

• sexual activity

• alcohol

• genetic factors

• age

• family history

• race

SYMPTOMS (1)

➢50% LUTS caused by the extrinsic

compression of prostatic urethra

leading to impaired voiding

• urinary hesitancy

• weak stream

• nocturia

Symptoms (2)

• Bladder overactivity

• Bladder underactivity

• Infra-vesical pathology

➢Urethral stricture

➢Overactivity of sphincter

MEDICAL CONDITIONS

WORSENING LUTS (1)• Dementia

• Stroke

• Alcoholism

• Parkinson’s disease

• Multiple sclerosis

• Diabetes

MEDICAL CONDITIONS

WORSENING LUTS (2)• Medication

• Confusion

• Impaired mobility

• Reduced manual dexterity

• Constipation

• Polyuria

• Acute medical illness

• Environmental factors

LUTS seen in BPH

STORAGE OBSTRUCTI

VE

OTHERS

Urgency

Frequency

Nocturia

Urge

incontinence

Stress

incontinence

Hesitancy

Poor flow

Intermittency

Straining

Dysuria

Incomplete

emptying

Postvoid

dribble

CAUTION!

➢Severity of symptoms do not always

correlate with size of prostate

➢BPH can be complicated by

• recurrent UTI

• gross haematuria

• bladder calculi

• acute urinary retention (AUR )

• obstructive uropathy

CLINICAL ASSESSMENT

3 main components :• Determining why the client presented

• Assessing the severity & type of

urinary symptoms

• Assessing the degree of bother

Determining why the client

presented to the clinic

• ? Reassurance

• concern about Ca prostate

• bothered about urinary symptoms

If client does not present with

urinary symptoms :

• How is your urinary stream?

Is it reduced?

• How many times do you get up to

pass urine?

• Are you bothered by your bladder

symptoms?

Other Urinary Symptoms

➢May require other Ix depending

on symptoms

• haematuria

• dysuria

• suprapubic pain

• incontinence

INTRODUCTION

• AB

INTERNATIONAL PROSTATE

SYMPTOM SCORE• quantify objectively the client’s

symptoms

• 7 questions with max score of 5

• Total score 35

• Scores

0 – 7 MILD

8 – 18 MODERATE

19 – 35 SEVERE

ASSESSING DEGREE

OF BOTHER

• affecting Quality Of Life ( QOL)

• a question in IPSS helps to

determine the client’s perception

of severity of symptoms

• helps client & physician to decide

the most appropriate management

strategy

EXAMINATION

• General physical examination

• Genito-urinary examination –

bladder / renal masses

• Digital Rectal Examination ( DRE )

in left lateral position

➢Size

➢Shape

➢Consistency of prostate

INVESTIGATION

• Urine analysis

• BUSE / Creatinine

• Ultrasound KUB

inc. bladder residual

• Plain X-ray KUB

• Prostate Specific Antigen (PSA)

KIV

• Urine cytology if urgency/haematuria

• IVU if haematuria +

MANAGEMENT

If MILD – MODERATE

➢ with “bother score”

➢Nil suspicion of Ca

➢Less than 50 ml bladder residual

Rx -REASSURE!

- watchful waiting

- medical Rx

- herbal Rx

WATCH & WAIT Rx

• Ideal in clients with

➢MILD-MODERATE urinary symptoms

➢Low “bother score”

• symptoms gradually worsen over time

• 2-2.5% chance of urinary retention

• In clients with MODERATE symptoms

➢Regular 6-12 month follow-up

➢25% risk of need for TURP in 4 years

ALPHA ADRENERGIC

BLOCKERS• Inhibit endogenous NA on smooth

muscle cells in prostate

• reduce prostate tone & BOO

• Side effects :-

➢Light headedness

➢Tiredness & lethargy

➢Postural hypotension

➢Palpitations & oedema

➢Headaches & ED

5 ALPHA REDUCTASE

INHIBITORS• Finasteride inhibits the intracellular

conversion of testosterone to

di-hydrotestosterone

• Reduces size of prostate ( ≥ 40 g )

• Min 3 months for benefit to occur

• Side effects :-

➢ED

➢Decreased libido

➢Decreased ejaculate volume

OTHER DRUGS

• PDE-5 Inhibitors induce smooth muscle

relaxation in bladder neck, prostate & urethra

• increase pelvic blood circulation

• Anticholinergics for bladder instability

( irritative symptoms )

• Propantheline, oxybutynin,

tricyclic anti-depressants

• X in clients with

• obstructive symptoms

HERBAL Rx ( PHYTOTHERAPY)

• Plant extracts

• Few side effects

• High client satisfaction

• Serenoa repens

• Certinin pollen extract

• Beta sitosterol

• ? Toxicity / side effects

HINTS TO AVOID

URINARY RETENTION

• Avoid certain medications

• Avoid “holding on”

• Take care with anaesthetics

• Keep warm in cold weather

• Avoid excess alcohol intake

• Avoid constipation

COMPLICATIONS OF BPH

➢Not responding to medical Rx

➢Poor compliance to drug Rx

➢Retention

➢Rec UTI

➢High residual

➢Bladder stones

➢Renal failure

INDICATIONS FOR REFERRAL

• Complications of BPH

• Suspect Ca prostate after DRE / PSA

• Predominantly irritative symptoms

• Raised creatinine

• Haematuria

• Moderate to severe symptoms

• Dislike medical Rx

• Failed initial Rx

• Fit for surgery

IF REFERRAL NECESSARY

• Urinary flow rate

• Urodynamic assessment

• Cystoscopy

• Transrectal ultrasound

• biopsy

CONCLUSION

➢ good rapport between the client and the

primary care doctor very helpful

➢ assess the “degree of bother”

➢symptoms may gradually worsen

over the years

➢conservative measures

➢ “Shared care” approach with Urology

➢10 -30% of men with severe

symptoms may need surgical options

INTRODUCTION