Benign Prostatic
Hyperplasia
Anoop Agrawal, M.D.
Baylor College of Medicine
Med-Peds Continuity Clinic
Prevalence of BPH
AUA BPH Algorithm
Medical History
Seven cardinal symptoms:
urinary frequency
nocturia
urgency
hesitancy
weak
straining to void
sensation of incomplete voiding
Initial Evaluation
History
Digital Rectal Exam & Focused Physical
Urinalysis
PSA
AUA Symptom Index Score
BPH: Diagnosis
Palpable prostate size does not correlate
with a diagnosis of BPH, nor with degree of
obstruction or the severity of symptoms.
Use urinary symptom scoring scale by the
American Urological Association to aid with
diagnosis.
consists of seven questions - each
question grades severity of each symptom
Differential Diagnosis
Diabetes
UTI
Neurogenic bladder
Urethral strictures
Cancer (bladder or prostate)
Medication induced
Laboratory Testing
Urinalysis
PSA
Optional tests:
urinary flow rate measurements
postvoid residual urine measurements
pressure flow studies
AUA Symptom Index
AUA Symptom Index:
Interpretation
Classification:
Mild: 0-7
Moderate: 8-19
Severe: 20-35
The AUA score needs to be put in the
context of whether the condition is or is not
bothersome.
Treatment
Studies have found that over a follow-up
period of 2.6 to 5 years, 16% men had stable
symptoms and 38% improved over time.
Treatment choices must take into account:
Symptom Index Score
Effect on quality of life
Case One
A 62 yo man reports nocturia, frequency and
urgency. His UA is negative, PSA is normal.
His AUA Severity Index is 10. He states the
symptoms are not very bothersome. What
treatment options do you recommend?
A. Watchful waiting
B. alpha-1 blocker
C. 5-alpha reductase inhibitor
D. Surgical therapy
Case One
A 62 yo man reports nocturia, frequency and
urgency. His UA is negative, PSA is normal.
His AUA Severity Index is 10. He states the
symptoms are not very bothersome. What
treatment options do you recommend?
A. Watchful waiting
B. alpha-1 blocker
C. 5-alpha reductase inhibitor
D. Surgical therapy
Treatment
Though symptom score may be above the
Mild range (0-7), initiating medical therapy is
not warranted unless patient finds he is
bothered by the symptoms.
May begin with behavior modifications:
reducing fluid intake at night
reducing consumption of mild diuretics
(caffeine and alcohol)
Treatment
Alpha-1 Blockers - common first line agent
Rapid onset, reduction in symptom score
by 30-40%
Nonselective Alpha-1 Blockers
SE: dizziness, orthostatic
hypotension, fatigue, asthenia;
occurs in 7-9%
Selective Alpha Blocker (tamsulosin,
alfuzosin) - less anti-hypertensive effect
Case Two
A 59 yo male presents with symptoms of BPH.
His rectal exam reveals a enlarged prostate.
You estimate at least 40 grams in size. His
AUA score is 16. He reports the symptoms
are very bothersome. What treatment options
do you recommend?
A. Watchful waiting
B. alpha-1 blocker
C. 5-alpha reductase inhibitor
D. Surgical therapy
Case Two
A 59 yo male presents with symptoms of BPH.
His rectal exam reveals a enlarged prostate.
You estimate at least 40 grams in size. His
AUA score is 18. He reports the symptoms
are very bothersome. What treatment options
do you recommend?
A. Watchful waiting
B. alpha-1 blocker
C. 5-alpha reductase inhibitor
D. Surgical therapy
Treatment: Case Two
5-alpha reductase inhibitors (finasteride,
dutasteride) these require long-term treatment (6-12
months) before symptom improvement is seen
more effective in men with large prostate
Combination therapy with alpha-1 blocker and 5alpha reductase inhibitors
found to be effective in men with severe
symptoms or men with moderate symptoms and
large prostate
Downside is that long-term safety of finasteride is
unknown
Combination Therapy in
BPH
McConnell, JD, Roehrborn, CG, Bautista, OM, et al. The long-term effect of doxazosin, finasteride, and
combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med 2003; 349:2387
Case Three
A 65 yo man with moderate symptoms of
BPH is worried about side effects from
alpha-1 blockers and wants to know if any
herbal remedies are recommended. What
do you advise?
Case Three
Complementary Medicine options
Genistein - an isoflavone found in tofu/soy
products, found to decrease growth of
hyperplastic prostate tissue in histoculture,
marketed as Trinovin, dose 40 to 80mg qd.
Saw palmetto - few side effects, safe, dosage
is 160mg bid
A 2006 prospective trial found no improvement
in symptoms. Current recommendation is to
avoid.
Case Four
A 55 yo man has been experiencing chronic
intermittent hematuria for past several
months. Urology performed a flexible
cystoscopy revealing no evidence of
malignancy or atypia. PSA is normal. What
treatment option is available to suppress
gross hematuria?
Finasteride - randomized trial of 57 men had
lower rate of recurrent hematuria (14 vs
63%)
Surgical Treatments
Open prostatectomy
Transurethral Resection of the Prostate (TURP)
Transurethral Incision of the Prostate (TUIP)
Transurethral Microwave Thermotherapy
(TUMT)
Transurethral vaporization of the prostate
(TUVP)
Transurethral needle ablation of the prostate
(TUNA)
AUA BPH Algorithm
Conclusion
Diagnosis based upon patients symptom
index and affect on quality of life
Wide range of treatment options - discuss
with patient benefits and risks.
Surgical therapy tends to be more effictive,
but results in more residual side effects.
References
Bent S, et al. Saw Palmetto for Benign
Prostatic Hyperplasia. NEJM 2006;
354:557-566.
Dull P, et al. Managing Benign Prostatic
Hyperplasia. Am Fam Physician
2002;66:77-84.
UpToDate 2009: Medical Treatment of
benign prostatic hyperplasia. (Accessed
February 21 & 22, 2009).
