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CPD Zone Update
www.chemistanddruggist.co.uk/update
UPDATE
Module 1638
»
This module covers:
DECEMBER
● The prevalence of benign prostatic
hyperplasia and associated problems
Men's health month
● The symptoms and clinical assessment of
patients with benign prostatic hyperplasia
● The latest treatment options, both on
prescription and over the counter, for benign
prostatic hyperplasia
● Red-flag symptoms for prostate cancer
● Alopecia
Dec 1
● BPH Dec 8
● Case studies Dec 15
Next week we look at erectile dysfunction,
gynaecomastia and testicular cancer
Benign prostatic hyperplasia
Rosemary Blackie
Benign prostatic hyperplasia (BPH) is the nonmalignant enlargement of the prostate gland.
It is a progressive condition and a common
part of ageing, and falls under the umbrella of
lower urinary tract symptoms (LUTS), which
cover storage, voiding and post-micturition
symptoms affecting the lower urinary tract.1 It
is not usually harmful and patients are not at
increased risk of prostate cancer.2
Around 3.2 million men in the UK3 suffer
from BPH and prevalence increases with age,
affecting around 40 per cent of men in their 50s
and 90 per cent of those in their 90s.1 Around
half of those with BPH have some form of
sexual problem3 and men of Afro-American
origin are more severely affected.1
In adult men the prostate gland surrounds
the urethra, is walnut-sized and is situated
between the penis and bladder. It produces
prostate specific antigen (PSA) which, when
mixed with semen from the seminal vesicles at
orgasm and ejaculation, causes the gelatinous
liquid to become more fluid.
The exact cause of prostate enlargement is
unknown but it may be due to an increase in
levels of dihydrotestosterone (DHT) as men age,
which stimulates prostate growth. Another
theory is that there is benign abnormal tissue
growth of fibrous, muscle and glandular tissue.14
Symptoms
Symptoms fall into two main groups:
Obstructive symptoms
● poor stream
● hesitancy
● dribbling
● straining
● incomplete or poor emptying.
Intermittent stream irritant symptoms
● frequency
● urgency
● feeling a need to pass urine even when
having just done so.
14 Chemist+Druggist 08.12.2012
Prostate size does not correspond in a linear
fashion with symptoms experienced, so the
effect on quality of life (bothersomeness) is
assessed using the International Prostate
Symptom Score (IPSS), an internationally
validated and approved scoring system
used as an aid to guide treatment.5 The IPSS
questions are shown in table 1 below;
an overall symptom score of zero to seven
indicates mildly symptomatic BPH; eight
to 19 moderately symptomatic; and 20 to 35
severely symptomatic.
For diagnosis of BPH, Nice guidelines
recommend5 that a medical history is taken
and a physical examination carried out,
including a digital rectal examination (DRE) to
assess the physical state of the prostate gland.
Checks should be made to ensure there is
no outflow obstruction in the bladder or that
symptoms are not due to nerve damage. Blood
tests should include a full blood count and urea
and electrolytes, and a dipstick test done for
signs of infection. The patient should also carry
out a urinary frequency volume chart to help ▶
Table 1. International Prostate Symptom Score (IPSS) questions
Severity of symptoms: scored zero (best) to five (worst), scored over the past month
Nature of symptom
Question
Score
(zero to five)
Incomplete emptying
How often have you had a sensation
of not emptying your bladder
completely after you finish urinating?
Frequency
How often have you had to urinate
again less than two hours after you
finished urinating?
Intermittency
How often have you found you
stopped and started again several
times when you urinated?
Urgency
How difficult have you found it to
postpone urination?
Weak stream
How often have you had a weak urine
stream?
Straining
How often have you had to push or
strain to begin urinating?
Nocturia
How may times did you typically get
up each night to urinate?
Quality of life score: If you were to spend the rest of your life with your urinary condition
the way it is now, how would you feel about that?
Delighted
0
Mostly dissatisfied
4
Pleased
1
Unhappy
5
Mostly satisfied
2
Terrible
6
Mixed
3
CPD Zone Update
assess symptoms,5 and any signs of urinary
tract obstruction should be further investigated
with imaging.1
A PSA test, which measures blood levels
of prostate specific antigen, should only be
offered if there are symptoms that suggest
bladder outlet obstruction secondary to BPH, an
abnormal prostate on DRE or concerns about
prostate cancer. Full information about the
limitations of the test should be provided.
On its own, the test cannot provide a
confirmatory diagnosis of either cancer or
BPH, as levels increase with age and vary from
person to person. Higher than normal reference
ranges can indicate prostate cancer, but can
also be caused by infection, vigorous exercise,
or a recently performed DRE. 'Normal' PSA
levels can also be present with cancer and
infection while alpha-blockers can reduce
PSA levels.6
Other conditions that present with
similar symptoms to BPH include prostate
cancer, upper urinary tract infection, bladder
tumours, stones or other traumas, chronic
pelvic pain, detrusor instability, urethral
stricture, chronic prostatitis, and interstitial
or radiation cystitis.
Treatment options
Patients without bothersome symptoms
or any complications should be offered
lifestyle interventions, reassurance and
review as necessary.5 Patients with mild or
moderate symptoms can be offered active
surveillance (watch and wait) or active
intervention treatment involving
conservative management, drug treatment
or surgery.
Alpha-blockers such as tamsulosin,
alfuzosin and doxazosin selectively block
peripheral alpha-1 adrenoceptors to relax
the smooth muscle of the bladder and prostate
neck, improving urine flow.
Symptom improvement is usually felt
within a few days, but can take up to six weeks.1
Alpha-blockers are recommended in moderate
to severe LUTS5 and the most common side
effects are postural-hypotension, drowsiness
and headaches.
The 5-alpha-reductase inhibitors
finasteride and duasteride block the
conversion of testosterone to DHT by the
enzyme 5-alpha reductase, to reduce prostate
size. This improves flow rate and obstructive
symptoms but it can take up to six months
to see full symptom improvement.7 They
are particularly suitable where there is a
significantly enlarged prostate8 and have been
shown to reduce long-term risk of acute
urinary retention and the need for surgery.1
Side effects include impotence, reduced
libido, breast tenderness and enlargement, and
reduced PSA markers. Condoms should be used
if the patient’s partner is pregnant or likely to
become pregnant, as these drugs are excreted
16 Chemist+Druggist 08.12.2012
in semen. Women of child-bearing potential
should avoid handling crushed or broken
tablets or capsules.8
Bothersome moderate to severe LUTS, where
the prostate is estimated to be over 30g or PSA
greater than 1.4ng/ml,5 can be treated with a
combination of alpha-blocker and 5-alphareductase inhibitor.
All treatments should be reviewed after
four to six weeks, and then every six to 12
months.5 Other treatment options include
anticholinergics for over-active bladder
and loop diuretics and desmopressin for
nocturnal polyuria.
Tadalafil has recently been licensed in
Europe for the treatment of the signs and
symptoms of BPH in adult males, including
those with erectile dysfunction, at a dose
of 5mg daily.9 It inhibits the enzyme
phosphodiesterase type-5, which results
in smooth muscle relaxation and
increased blood flow.11 It is contraindicated
with concurrent nitrates due to a risk of severe
hypotension.
Where symptoms are very bothersome, or
medication does not help or is unsuitable,
surgery is an option. Around a quarter of
those with enlarged prostate will undergo
surgery.1 In addition, there is some evidence
that saw palmetto can help in BPH, especially
in frequency and nocturia,4 and also a small
evidence-base for beta-sitosterol.12
Various lifestyle measures can be undertaken
to reduce the impact of BPH on everyday
life and should be advised with or without
medication. These include anticipating when
frequency or urgency could be a problem – on
long journeys, for example – and avoiding
drinking too much in the previous two to three
hours.
Double micturition – returning to the
toilet a few minutes after urination to try
to pass more urine – can help ensure the
bladder is fully empty. Caffeine and alcohol can
worsen frequency, nocturia and urgency, and so
should be stopped or reduced, as
should smoking.
Patients can also be advised to try to relax
when passing urine, use distraction
techniques if urgency is a particular
problem and avoid drinking in the two to
three hours before bed.
Bladder retraining, where the patient tries to
hold on for as long as possible before passing
urine, can also help to expand and strengthen
the bladder muscle.
Initially, a symptoms questionnaire must
be completed by the patient, which includes
the IPSS, and the patient must meet all the
following conditions:
● Aged between 45 and 75 years
● Has experienced symptoms for more than
three months
● Is not currently being treated for BPH.
If the patient has either an IPSS symptom
score of eight or more, or a symptom score
of at least one and a quality of life score of
four or more, the patient is eligible for an
initial two-week supply. The patient should
then be directed to their GP for confirmation
of the diagnosis.
After two weeks the patient should be
reassessed, and a further four-week supply
can be sold if symptoms have improved; no
further supplies can be made after this sixweek period if the patient has not consulted
his GP.
Following this, up to 52 weeks can be
supplied (in monthly amounts) and the
patient reviewed by their GP annually. Flomax
should be taken the same time each day after
food, and it is important to encourage the
patient to continue to take capsules even if
he feels much better, as BPH is a progressive
condition.
Patients with pain on urination, bloody or
cloudy urine within the last three months,
unexplained fever, urinary incontinence,
unstable or undiagnosed diabetes or liver,
kidney or heart problems are not suitable for
OTC treatment and should be referred to their
GP.
OTC treatment
Further resources
Nice guidelines indicate LUTS can initially be
assessed and treated, if appropriate, in a nonspecialist setting. Flomax Relief (tamsulosin)
was launched in 2010 in an effort to capture
those who do not or will not go to the GP for
various reasons, including embarrassment and
lack of time.
● Flomax website – www. myilearn.co.uk/
flomax
● Flomax Relief support staff training guide
– www. myilearn.co.uk/flomax/resources/
documents/Flomax_Relief_Pharmacy_
Support_Staff_Training_Guide.pdf
● Flomax patient support – ▶
Prostate cancer
Prostate cancer is the most common male
cancer, with around 40,000 cases diagnosed in
the UK each year, and the most common cause
of cancer-related death in men.3 Symptoms
are often non-specific and in line with other
LUTS, but haematuria and pain on ejaculation
are two of the red-flag symptoms. Risk factors
for prostate cancer include:
● increasing age
● family history of breast or prostate cancer
● African ethnicity
● a diet high in saturated fat and red meat
with little fruit and vegetables.
The PSA test is used to aid diagnosis,
together with further investigation, including
biopsy. There is no screening programme,
but there is an NHS Prostate Cancer Risk
Management programme.
CPD Zone Update
5 minute test
■ Sign up to take the 5 Minute Test and get your answers
marked online: chemistanddruggist.co.uk/update
Take the 5 Minute Test
1. Patients who have BPH have an increased
risk of prostate cancer.
True or false?
2. BPH affects around 3.2 million men in
the UK.
True or false?
3. Three-quarters of men with BPH also have
some form of sexual problem.
True or false?
4. A patient with a score of 10 from the IPSS
questionnaire would be considered to have
severely symptomatic BPH.
True or false?
5. A prostate specific antigen test provides
confirmation of a diagnosis of BPH.
True or false?
6. Side effects of tamsulosin include postural
hypotension, drowsiness and headache.
True or false?
7. Finasteride acts by relaxing the smooth
muscle of the bladder and prostate neck.
True or false?
www. flomaxrelief.co.uk
● Prostate Action UK – www. prostateaction.
org.uk
● NHS Choices – www.nhs.uk/conditions/
Prostate-disease
● NHS Prostate Cancer Risk Management
Programme – www. cancerscreening.nhs.uk/
prostate
References
1. Patient UK Plus. Benign prostatic hyperplasia.
www.patient.co.uk/doctor/benign-prostatichyperplasia
2. Prostate Enlargement. NHS Choices.
www.nhs.uk/conditions/prostate-enlargement
3. Prostate Action UK. Benign prostatic
hyperplasia (BPH) facts and figures.
www. prostateaction.org.uk
4. A. Vogel. Enlarged Prostate Pharmacy herbal
handbook 2. 2012
5. Nice. The management of lower urinary tract
symptoms in men Clinical Guideline 97. May
2010
6. Clinical Knowledge Summaries. Lower
urinary tract symptoms in men, age-related
(including symptoms of benign prostatic
hyperplasia/hypertrophy). cks.nhs.uk
7. Pfizer. Finasteride summary of product
characteristics 2012.
8. British National Formulary. Number 64.
September 2012. bnf.org
9. Cialis. Summary of opinion (post
authorisation). European Medicines Agency.
18 Chemist+Druggist 08.12.2012
8. Sildenafil is licensed for the treatment
of the signs and symptoms of BPH.
True or false?
9. OTC tamsulosin is suitable for men aged 40
to 70 years who have experienced symptoms
for longer than six months.
True or false?
10. Patients started on OTC tamsulosin must
see their GP within six week for diagnosis
confirmation.
True or false?
Update 2013
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September 20, 2012
10. Eli Lilly and Company UK. Cialis (tadalafil)
backgrounder (2of 2). November 2012
11. Eli Lilly and Company UK. Cialis summary of
product characterisitics 12. Bandolier medicine.
Beta-sitosterol for benign prostatic hyperplasia
13. Boehringer Ingleheim. Flomax Relief
MR pharmacy support staff training guide.
December 2009
14. BPH. General Practice Notebook
Tips for your CPD entry
on benign prostatic
hyperplasia
Reflect How are the symptoms of benign
prostatic hyperplasia (BPH) assessed?
How do 5-alpha-reductase inhibitors
work? What criteria must be fulfilled for
OTC treatment of BPH with tamsulosin?
Plan
This article describes the symptoms
and diagnosis of BPH and includes
information about treatment options
such as alpha-blockers and 5-alphareductase inhibitors. Lifestyle advice,
prostate cancer and OTC treatment are
also discussed.
Act Read the article and the suggested
reading below, then take the 5 Minute Test
(left). Update subscribers can then access
their answers and a pre-filled CPD logsheet.
Learn more about BPH from NHS Choices.
http://tinyurl.com/prostate11
Read the prostate gland enlargement
management options brief decision
aid on the Patient UK website, which
summarises treatment benefits and risks.
http://tinyurl.com/prostate12
Revise your knowledge of the OTC supply
of tamsulosin with the Flomax Relief
training materials.
http://tinyurl.com/prostate13
Find out more about prostate cancer from
the Cancer Research UK website and the
PSA test from the Patient UK website.
http://tinyurl.com/prostate14
http://tinyurl.com/prostate15
Read the MUR tips for BPH from C+D.
http://tinyurl.com/prostate16
Evaluate
Are you now confident in
your knowledge of BPH? Could you give
advice to patients about treatment
options and lifestyle?