Urology Update Sanofi- Aventis
Kenneth Lim, D.O.
Urology Residency Director
POH/ Detroit Medical Center
BPH and Aging
Diseases of the Prostate
BPH / LUTS / OAB / RetentionSigns and SymptomsMedical Management
Prostate Cancer Detection
Anatomy of BPH
Kirby RS et al. Benign prostatic hyperplasia. Health Press, 1995.
NormalNormal BPHBPH
Hypertrophied detrusor muscle
Obstructed urinary flow
Prostate
Bladder
Urethra
Symptoms Suggestive of BPH
Obstructive (Voiding)
Weak stream Prolonged micturition Straining Hesitancy Intermittent stream Feeling of incomplete
bladder emptying
Irritative (Storage)
Frequency Nocturia Urgency Incontinence
American Urological Association Symptom Index (AUA-SI)
AUA Practice Guidelines Committee. J Urol. 2003;170(2 Pt 1):530537. Barry MJ et al. J Urol. 1992;148:15491557.
Incomplete bladder emptying
Frequency Intermittency Urgency Weak stream Straining Nocturia
AUA Symptom Index (AUA-SI)AUA Symptom Index (AUA-SI)
ClassificationClassification
MildMild
ModerateModerate
SevereSevere
ClassificationClassification
MildMild
ModerateModerate
SevereSevere
AUA-SIAUA-SI
0 – 70 – 7
8 – 198 – 19
20 – 3520 – 35
AUA-SIAUA-SI
0 – 70 – 7
8 – 198 – 19
20 – 3520 – 35
Criteria to Determine Treatment
AUA Symptom Score (Quality of Life)Elevated Post-Void Residual
UTIHematuriaBladder calculusRetention
Medical Management for Symptomatic BPH
Alpha blockers5 Alpha reductase inhibitorsCombinationOAB drugsObservation
Pharmacotherapy of BPH
Alpha Blockers 5ARIs
Relax smooth muscleRelax smooth muscle• Improve symptomsImprove symptoms
Reduce the prostate volumeReduce the prostate volume• Improve symptomsImprove symptoms• Arrest the disease processArrest the disease process
McConnell JD et al. N Engl J Med. 2003;349:23872398.
Alpha-Blockers (Uroxatral, Flomax)
Offers symptomatic relief within days/weeks
Does not change size of prostateSide effects
Nasal stuffiness, orthostatic hypotensionFlomax – retrograde ejaculation Uroxatral – no retrograde ejaculatio
5 Alpha Reductase Inhibitor (Proscar, Avodart)
Slower effect on urinary symptoms than alpha blockers
Prostate size reductionUrinary retention risk reduction
Selection Criteria
If Signs & Symptoms – Moderate to Severe (prostate size < 30-40 gms)Alpha blocker - 2 weeksCystoscopy +/- Prostate Ultrasound
If Signs & Symptoms - Moderate to Severe (prostate size > 50 gmsAlpha blocker + 5 alpha reductase inhibitor
OAB Drugs
Direct action on bladderStorageUrgency, frequency
American Cancer Society Screening Guidelines
DRE and PSA - Annually Age 50 – no risk factors Age 40 - Family history of Ca – Breast or
Prostate - baseline prostate ultrasound
NEJM 5/04: PSA Inaccurate as Screening Test for Prostate Cancer
15 % of Patients with normal PSA diagnosed with Prostate Cancer
PSA – single best test for prostate cancer screening
DRE and Prostate Ultrasound to compliment PSA
TRUS Biopsy when any abnormality
Age related norms for PSA
40-49 < 2.5 ng/ml50-59 < 3.5 ng/ml60-69 < 4.5 ng/ml70-79 < 6.5 ng/ml
PSA
PSA velocity - .75 ng/ ml / year PSA velocity(2-4) - .4 ng / ml / year
PSA 4-10 % Free PSA > 20 low risk 10 – 20 intermediate risk < 10 high risk
What to do with an abnormal PSA?
1. Look for a previous PSA, DRE If DRE abnormal, proceed to Biopsy
2. Cipro 500mg BID x 2 weeks3. Free and Total PSA4. Assess Cancer Risks for Biopsy5. Biopsy when in Doubt
Prostate Ultrasound Biopsies
Sextant format, local anesthesia, 10-12 biopsies
Saturation biopsies – 1 biopsy / gmIndications for biopsies
Abnormal PSA – high risk free PSA, PSA density
Abnormal DREAbnormal prostate ultrasound
The Buzz: Robot Prostatectomy
Better Cancer CureLess Impotence, Blood lossHigher IncontinenceShorter Hospitalization
NEJM 4 / 08: Robot vs. Open Prostatectomy
Conclusion: No DifferenceSelection determined by patient bias