MANAGING BENIGN PROSTATIC HYPERTROPHY IN PRIMARY CARE DR GEORGE G MATHEW CONSULTANT FAMILY PHYSICIAN FELLOW IN SEXUAL & REPRODUCTIVE HEALTH

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

AB INTRODUCTION

AB INTRODUCTION

AB INTRODUCTION

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 Urgency Frequency Nocturia Urge incontinence Stress incontinence OBSTRUCTI VE Hesitancy Poor flow Intermittency Straining Dysuria Incomplete emptying OTHERS 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

AB INTRODUCTION

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