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 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 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 ↓ serum DHT by 60-75% Reduction of prostate volume 20-30% Reversal of BPH process Relief of obstruction ↑ uroflow 2.7ml/sec Finasteride 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 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 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 Prostatic stents (temporary and permanent) Electrovaporization Laser ablation – – – 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 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 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!