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All About the Prostate For Intelligent Internists Part 1: Benign Prostatic Hyperplasia Objectives Part A: Diagnosis Formulate a differential diagnosis for LUTS Perform appropriate evaluation/ w/u Use the AUA symptom score to assess severity Part B: Management counsel on what to expect from medications appropriately manage persistent symptoms Diagnosis: MKSAP! • An 80-year-old man is evaluated for a 1-year history of progressive urinary symptoms including weak stream, hesitancy, and nocturia four times nightly. He has coronary artery disease and chronic heart failure. His current medications are lisinopril, isosorbide dinitrate, aspirin, and metoprolol. • On physical examination, vital signs are normal. He has mild suprapubic tenderness and a symmetrically enlarged prostate without nodules or tenderness. The remainder of the physical examination is normal. • Which of the following is the most appropriate diagnostic test to perform next? A. Postvoid residual urinary volume measurement B. Plasma glucose level C. Prostate-specific antigen testing D. Transrectal ultrasound E. Urinalysis Anatomy of a large prostate • Prevalence: 25% of men in 40s, 80% in 70s • not all are symptomatic LUTS! More than half of men in their 60s have LUTS • LUTS ≠ BPH • Storage, Voiding, Postmicturition Sx Differential Diagnosis • bladder irritants (e.g. caffeine, alcohol) or excess fluid • Diuretics, anticholinergic, antihistaminic meds • UTI/prostatitis • Overactive Bladder • Neurogenic Bladder (e.g. parkinson’s, spinal cord) • Bladder, prostate Ca Workup • U/a generally indicated • (eval for UTI/hematuria) • *Consider* DRE/PSA to evaluate for prostate ca after discussing risks/harms • Might also consider DRE to evaluate prostate size as it pertains to management • PVR if sensation of incomplete emptying (or renal insufficiency and suspect postrenal issue) Diagnosis: MKSAP! • An 80-year-old man is evaluated for a 1-year history of progressive urinary symptoms including weak stream, hesitancy, and nocturia four times nightly. He has coronary artery disease and chronic heart failure. His current medications are lisinopril, isosorbide dinitrate, aspirin, and metoprolol. • On physical examination, vital signs are normal. He has mild suprapubic tenderness and a symmetrically enlarged prostate without nodules or tenderness. The remainder of the physical examination is normal. • Which of the following is the most appropriate diagnostic test to perform next? A. Postvoid residual urinary volume measurement B. Plasma glucose level C. Prostate-specific antigen testing D. Transrectal ultrasound E. Urinalysis AUA Symptom Score/I-PSS • Part of initial evaluation that can help confirm dx and guide management • 35 point scale • In prism: .aua • Used to evaluate response to therapy • 3-4 point difference clinically significant Objectives Part A: Diagnosis Formulate a differential diagnosis for LUTS Perform appropriate evaluation/ w/u Use the AUA symptom score to assess severity Part B: Management counsel on what to expect from medications appropriately manage persistent symptoms Management: MKSAP! • A 68-year-old man is evaluated for continuing urinary frequency and nocturia. His symptoms have been slowly progressive over the past 1 to 2 years with a weak urinary stream and hesitancy. He was started on doxazosin 6 months ago, which he tolerates well and initially provided some improvement. However, his symptoms have continued and are beginning to interfere with his quality of life, particularly the urinary frequency and nocturia. His only other medical problem is hypertension, for which he takes lisinopril and metoprolol. • On physical examination, he is afebrile, blood pressure is 140/85 mm Hg, pulse rate is 70/min, and respiration rate is 14/min. BMI is 25. He has a symmetric moderately enlarged prostate gland with no prostate nodules or areas of tenderness. A urinalysis is normal. • Which of the following is most appropriate next step in treatment of this patient's benign prostatic hyperplasia? A. Add finasteride B. Change doxazosin to finasteride C. Change doxazosin to tamsulosin D. Prescribe a fluoroquinolone antibiotic for 4 weeks Management • AUA < 8 -> watchful waiting usually appropriate • AUA >8 usually med mgmt • Keep it patient centered! depends on how bothersome sx are. • Absolute indications for treatment? • • • • Postrenal AKI Urinary retention (PVR >250? 300?) Bladder stones Recurrent UTIs Alpha-1 blockers • All equally effective in head to head studies • More efficacious than finasteride for reducing symptoms • Selective have a better safety profile, but more $ 5-α reductase inhibitors Finasteride/Dutasteride • Decreases size of prostate (part of inclusion criteria for studies: prostates>30 g on US, PSA >1.5) • 5-year trial shown to decrease risk of urinary retention and surgery • Takes ~6 months for improvement in AUA score Side Effects • Decreased libido, ED, gynecomastia • Will decrease PSA by ~50% at 6 months • May reduce incidence of prostate cancer overall but increase risk of high grade prostate ca Combination therapy • One-year trial 1996 showed combination therapy not superior to terazosin alone in reducing symptom scores and urinary flow rates • MTOPS trial 2003: • mean f/u 4.5 years • AUA score 8-30 • Composite Primary Outcome: Clinical progression • increase in AUA score ≥4, acute urinary retention, renal insufficiency, incontinence, recurrent UTI • Secondary outcomes: improvement in AUA score MTOPS Take-Homes Significant reduction in composite clinical progression with combination than either doxazosin or finasteride alone not better than alpha blocker alone in preventing progression of AUA scores (although AUA more improved by year 5 with combo vs. doxazosin alone: 7 points vs. -6) not better than finasteride alone in risk of urinary retention/invasive therapy more AEs, more $ Who might you choose combo tx for? failure of alpha blocker tx alone large prostate size/higher PSA? higher AUA score? Urinary retention? - Other options • Antimuscarinics (oxybutynin) • If predominantly storage sx (frequency, urgency) • In men with PVR <250, reduced symptoms when added to α –blocker, did not increase risk of retention • PDE inhibitors (tadalafil 5 mg daily) • PDE present in prostatic tissue: PDE-I may enhance smooth muscle relaxation, decrease proliferation of hyperplasia • Reduced AUA score 3.8 points at 12 weeks • Saw Palmetto? Data does not show efficacy When to Refer to Urology • Refractory sx • Urinary retention • recurrent UTIs • Rising PSA if you choose to monitor (e.g. on 5alpha reductase inhibitor) Management: MKSAP! • A 68-year-old man is evaluated for continuing urinary frequency and nocturia. His symptoms have been slowly progressive over the past 1 to 2 years with a weak urinary stream and hesitancy. He was started on doxazosin 6 months ago, which he tolerates well and initially provided some improvement. However, his symptoms have continued and are beginning to interfere with his quality of life, particularly the urinary frequency and nocturia. His only other medical problem is hypertension, for which he takes lisinopril and metoprolol. • On physical examination, he is afebrile, blood pressure is 140/85 mm Hg, pulse rate is 70/min, and respiration rate is 14/min. BMI is 25. He has a symmetric moderately enlarged prostate gland with no prostate nodules or areas of tenderness. A urinalysis is normal. • Which of the following is most appropriate next step in treatment of this patient's benign prostatic hyperplasia? A. Add finasteride B. Change doxazosin to finasteride C. Change doxazosin to tamsulosin D. Prescribe a fluoroquinolone antibiotic for 4 weeks