Benign Prostate Hyperplasia (BPH) The Shared Care Concept Dr Yip

Benign Prostate Hyperplasia
(BPH)
The Shared Care Concept
Dr Yip Wai Chun
Urology Division
Department of Surgery
Kwong Wah Hospital
Prostate Disease
Prostatitis 2%
Prostatic cancer
18%
BPH 80%
Prostatic problems
↑number of patients
1.
2.
3.
Ageing population
↑public awareness
Effective medical treatments
BPH is the most prevalent disease
to affect men beyond middle age
45
40
35
30
25
(%)
Age (years)
20
15
10
5
0
40-49
50-59
60
Three fundamental features of
Benign Prostatic Hyperplasia
Hyperplasia
Symptoms
Obstruction
Benign Prostatic Hyperplasia
Morphology of the
prostate gland
Why does Prostate enlarge ?
Multifactorial
Due to
1. Ageing
2. Presence of androgen
What is enlarged ?
1.
2.
Stromal nodules – smooth muscle &
connective tissue
Glandular hyperplasia
Compression
on the urethra
Detrusor instability (70%)
(Reduced parasympathetic innervation)
Frequency, urge
Lower urinary tract symptoms
(Prostatism)
Obstructive
Irritative
„ weak stream
„ urgency
„ straining
„ frequency
„ incomplete
„ nocturia
emptying
„ urge incontinence
„ prolonged voiding
„ hesitancy
„ terminal dribbling
„ retention
Effects of bladder outflow
obstruction
Adverse effects of the symptoms of
BPH on activities of daily living
„
„
„
„
„
„
„
Limits fluid intake before travel
Restricts fluid intake before bedtime
Cannot drive for 2 hours without a break
Disruption of sleep
Limits going to places without toilets
Limits playing outdoor sports
Avoids, e.g. going to cinema, theatre or
church
BPH
„
Mild disease
troublesome, major
source of discomfort
impair quality of life
„
Severe disease
complications
impaired renal function
The symptoms of BPH may remain
unchanged or deteriorate only slowly
over time
Improved with time: 15%
Worsening symptoms: 55%
Remain stable: 30%
Basic Evaluation of BPH
1.
2.
3.
4.
5.
Detailed history
Symptom assessment
Physical examination
DRE
Urinalysis, renal function test, KUB
PSA < 75 age
Interpretation of IPSS values
(total score=35)
0 -7
8-18
>18
mild
moderate
severe
Differential diagnosis of lower
urinary tract symptoms
„
Neurological conditions
– Parkinson’s disease
– Cerebrovascular
accident
– Multiple system atrophy
( Shy-Drager syndrome)
– Cerebral atrophy
– Multiple sclerosis
„
Neoplastic disorders
– Prostatic cancer
– Carcinoma in situ of the
bladder
„
Inflammatory disorders
– Urinary tract
infection/bladder stone
– Interstitial cystitis
– Tuberculous cystitis
„
Other causes of
obstruction
– Bladder neck
dyssynergia
– External sphincter
dyssynergia
– Urethral stricture
Digital rectal examination
Digital rectal examination
(DRE)
„
„
size : normal gland like a chestnut (20
gm)
consistency :
– smooth or elastic - normal
– hard - may indicate cancer
– tender - suggest prostatitis
„
„
mobility
anatomical limit :
– median sulcus, seminal vesicles
血液和尿液檢查
Creatinine and Electrolytes
10% of patients
Renal impairment
X 光照片檢查 (KUB)
Features of prostate-specific
antigen
„
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„
„
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glycoprotein whose function is to liquify
semen
produced exclusively by prostatic epithelium
normal serum value less than 4 ng/ml
elevated in 25% of patients with BPH
increased in most cases of prostate cancer
tends to rise progressively with age and
prostatic volume
Interpretation of prostatespecific antigen (PSA) values
PSA value
„ < 4 ng/ml
„ 4-10 ng/ml
„ > 10 ng/ml
Interpretation
„ 8% cancer
„ 20-25% cancer
„ >50% cancer
Recommended age-adjusted
PSA cut-off values
Age (years)
„
„
„
„
40 - 49
50 - 59
60 - 69
70 - 79
PSA cut off value
(ng/ml)
„ 2.5
„ 3.5
„ 4.5
„ 6.5
need at least 150 ml
> 15 ml/sec : normal
< 10 ml/sec : obstructed
Evidence of obstructive BPH
„
„
„
Prostate on TRUS > 20g
Symptoms of urinary dysfunction
Peak FR < 15 ml/sec
Symptoms indication for
need of prostate surgery
„ Poor
flow
„ Sensation of incomplete voiding
Management
„
„
watchful waiting
medical therapy
– α blocker
– Finasteride
– phytotherapy
„
surgical therapy
Natural history of BPH
60%
50%
40%
worse
same
better
30%
20%
10%
0%
BPH symptoms
Low symptom scores
Watchful waiting
Periodic evaluation
Medical therapy
„ First
line treatment
„ Mild-to-moderate symptoms
Effect of αblocker
Effects of α1-blockers
1.
2.
3.
Improve most symptoms of
BPH
Enhance uroflow by 3ml/sec
Effective – 60 % of patients
α1-blockers
Adverse effects
1.
2.
3.
4.
5.
Drowsiness, headache 10-15%
Dizziness, postural hypotension 25%
Retrograde or delayed ejaculation
Nasal congestion
Reflex tachycardia
Require gradual dose titration
α 1 adrenoceptor
blockers
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Prazosin : 3 times per day
terazosin : once per day
doxazosin : once per day
doxazosin GITS : once per day
alfuzosin IR : 3 times per day
alfuzosin SR : 2 times per day
tamsulosin : once per day
5 α-Reductase Inhibitor
(Finasteride)
Mechanism of action
5- α reductase
Finasteride
Testosterone
X
(DHT)
dihydrotestosterone
Effects of Finasteride
„
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„
„
„
↓ serum DHT by 60-75%
Reduction of prostate volume
20-30%
Reversal of BPH process
Relief of obstruction
↑ uroflow 2.7ml/sec
Finasteride
„
„
„
„
„
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Large prostate (>40-50g) responds
better
Recurrent bleeding case
5mg/day
Time to onset of action 3-6 months
↓serum PSA by 50 %
Reverse male pattern balding
Finasteride – Adverse
Effect
„
„
„
„
Erectile dysfunction
Decreased libido
Reduced ejaculate vol
Gynaecomastia
3-5%
3-4%
(>30%)
rare
Combination Therapy
α1 blocker + 5 α reductase inhibitor
„
„
„
Controversial
3 studies --- no benefit
MTOPS --- 67% reduction in disease
progression
↓AUR
↓need invasive therapy
improve symptom score
Phytotherapy
„ Effect
not established
„ Placebo action only
„
Nearly Half of Men on Alpha Blockers
still Have Bladder Control Problems
Detrusitol 1 mg or 2 mg
BD
Recent Studies of Tolterodine in
Men with OAB/LUTS: Efficacy
Athanasopoulos et al., 2003:
Lee et al., 2004
•
•
Open label, doxazosin 4mg/day
If no symptomatic improvement,
add tolterodine IR
Improved
Double-blind (N=50)
•
Tolterodine IR vs. pbo, added to
Not
Improved
35%
Doxazosin
Doxazosin
(N=60)
(N=60)
•
tamsulosin 0.4 mg/day
Improvement in QoL (p<0.05)
65%
Kaplan et al., 2004
•
Doxazosin
Doxazosin
Plus
Plus Tolterodine
Tolterodine
•
73%
Improved
27%
Not
Improved
Improvement = 3pt reduction on IPSS
Athanasopoulos A et al., J Urol 2003: 169:2253-6
Kaplan SA, Walmsley K, Te AE, J Urol 2004: 171:243
Lee JY, Kim HW, Lee SJ, et al., BJU Int 2004: 94:817-20
Open, tolterodine ER, 6 months
Males with LUTS who have failed
alpha blocker therapy (N=43)
Reduction in frequency & nocturia
Safety on OAB/LUTS treatment
Incidence of Urinary Retention in POC trials
„
„
Tolterodine + alpha blocker (3 months)
– 0/25
(Atanasopoulos)
– 1/60
(Lee)
Tolterodine monotherapy (3-6 months)
– 0/149 (Abrams/Pfizer study 062)
„
25 ml average increase in PVR not considered clinically
significant
„
1/72 on placebo
– 0/43
(Kaplan)
Incidence of Urinary Retention in BPH Patients: 0.5-2.5% /year
Roehrborn, 2001
Athanasopoulos A et al., J Urol 2003: 169:2253-6
Kaplan SA, Walmsley K, Te AE, J Urol 2004: 171:243
Lee JY, Kim HW, Lee SJ, et al., BJU Int 2004: 94:817-20
Abrams P, J Urol 167: 266, 2002.
Contraindications to
medical treatment of BPH
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Recurrent acute urinary retention
Palpable bladder, large volume of post-void
residual (PVR) urine (>300ml)
Renal insufficiency
Recent haematuria
Recurrent urinary tract infections secondary
to BPH
Bladder stones or diverticula
Evidence of prostate cancer
Surgical treatment for
BPH
Transurethral resection of the prostate (TURP)
Transurethral Resection
of Prostate gland
„
Advantages
– early recovery and shorter hospital stay
– no wound
„
Disadvantages
– morbidity of 18%
– mortality of 1%
Morbidity of TURP
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Retrograde ejaculation
urethral stricture
incontinence
impotence
failure to void
postoperative haemorrhage
bladder neck contracture
TUR syndrome
70%
5%
1%
15%
6%
4%
3%
2%
Irritative symptoms
(frequency & urgency)
„ May
persist for up to 1 year
after TURP
(gradual renervation)
Minimally invasive approaches
to the treatment of BPH
„
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„
Prostatic stents (temporary and permanent)
Electrovaporization
Laser ablation
–
–
–
„
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Transurethral laser incision of prostate (TULIP)
Endoscopic laser ablation of the prostate (ELAP)
Interstitial laser therapy
Transurethral needle ablation (TUNA)
Transurethral microwave thermotherapy
(TUMT)
Transrectal and transurethral hyperthermia
Surgical treatment for
BPH
Transurethral electrovaporization of the prostate (TUEVP)
Technological intervention
for BPH
Balloon dilatation
Permanent stent
Technological intervention
for BPH
Transurethral needle ablation
of the prostate (TUNA)
High -intensity focused
ultrasound (HIFU)
Technological intervention
for BPH
Transrectal hyperthermia
Transurethral microwave
thermotherapy (TUMT)
Technological intervention
for BPH
Interstitial laser coagulation of the prostate (ILC)
Technological intervention
for BPH
Transurethral laser incision
of the prostate (TULIP)
Visual laser ablation
of the prostate (VLAP)
TUR-P
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„
„
Not an easy decision
Postoperative morbidity 15-16%
10-20% requires 2nd procedure within
10 years
Patients like less invasive method of
treatment
Shared Care for Prostatic
Disease
Family practitioners and urologists
working together to improve patient care
Patient’s Misunderstanding
BPH symptoms – ageing problem
∴ the problem remains neglected
underdiagnosed &
untreated
The need for family physicians
1.
2.
3.
4.
5.
6.
↑patient volume
Seek for better quality of
life
Effective medical
treatment
↑patient awareness
Prostate health check
Alertness for prostatic
cancer
7.
Encourage by
government &
insurance companies
Treatment
Role of family physicians
„
„
Mild-to-moderate symptoms of BPH
are extremely prevalent
medical treatment, surgical
treatment (TURP)
Case Presentation
1.
2.
Seeking reassurance
Urinary tract symptoms
Family Physician
Detecting Prostatic Disease
Ask three questions
1.
2.
3.
Do you get up at night to pass urine ?
Is your urinary stream reduced?
Are you bothered by bladder symptoms?
Yes – two out the three questions
BPH
Family Physicians Management Scheme (1)
Case finding
Three Qs
IPSS
Rectal examination
Urinalysis
RFT
KUB
PSA
Severity
QoL
Prostate
size
BPH
Family Physicians Management Scheme (2)
± Flow Rate
± Residual urine volume
Medical treatment
Follow up (3 months)
Continue medication
Symptoms
improvement
Guidelines for the diagnosis and management of BPH
Patient seeking
reassurance
•
•
•
•
•
• IPSS and history
• DRE/abdominal examination
• Urinalysis (if positive take urine
microscopy culture)
• PSA estimation
• PVR and flow rate, if possible
High symptom score
Abnormal DRE
Palpable bladder
History of recurrent UTI/haematuria
PSA abnormal
Refer to urologist
•
•
•
•
Flow rate
PVR urine measurement
Urodynamic studies
TRUS and biospy
Surgical treatment if clearly
obstructed and ‘bothered by
symptoms
•
•
•
•
•
Patients presenting
with urinary tract
symptoms
Moderate symptom score/ litter bother
Benign prostate on DRE
Impalpable bladder
No urinary tract infection/haematuria
Normal PSA
Litter bother
Bothersome symptoms
Watchful waiting
Medical treatment
Review in 12
months
Review in 3-6 months
• Deterioration or no response to treatment
• PSA increased by >20%
When to refer to urologist
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Markedly elevated symptom score
Very reduced flow rate
Haematuria, bladder stone or recurrent UTI
Palpable bladder, urinary retention
Real impairment or upper tract dilatation
Failed medical treatment
Abnormal DRE, PSA>4.0 ng/ml
Thank You!