managing benign prostatic hypertrophy …...benign prostate hypertrophy (bph) affects •42% of men...
TRANSCRIPT
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