The Aging Prostate: Presentation, Diagnosis

1
The Aging Prostate Presentation, Diagnosis
Management

• Professor Riyadh F. Talic, MD
• Professor of Urology Andrology
• College of Medicine, King Khalid University
  Hospital
• And Consultant Urologist Andrologist at
  Specialized Medical Center, SMC

2
Etiology of BPH

• Increasing Age
• Testosterone

3
Prevelance of BPH Aging
88
50
60 yrs
At 80 yrs
4
Aging Prostate Terminology

• Benign Prostatic Hypertrophy (BPH)
• Benign Prostatic Obstruction (BPO)
• Lower Urinary tract symptoms (LUTS)

5
Benign Prostatic Hypertrophy
BPH
LUTS
Urinary Obstruction
Bladder dysfunction
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Prostatic LUTS

• Storage LUTS
• (i.e. irritative LUTS)
• Frequency
• Nocturia
• Urgency
• Urge incontinence

• Voiding LUTS
• (i.e. obstructive LUTS)
• Hesitancy
• Weak stream
• Intermittency
• Sense of incomplete emptying

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Causes for Storage LUTS (Irritative LUTS)

• Urinary Outflow Obstruction
• Locally irritating pathology
• Neuro-vesical dysfunction

Cystitis
Tumors
Stones
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Adverse effects of BPH

• Erodes Quality of Life
• Complications
• Urinary retention
• Recurrent hematuria
• Bladder stones
• Compromised renal function

9
BPH effects on Quality of Life

• Limits fluids before travel
  58
• Limits fluids before bed time 63
• Cannot drive for more than 2 hours 51
• Not getting enough sleep at night 51
• Avoids places without toilets 62
• Limits playing outdoor sports 33
• 
  Tsang et al Prostate 1993

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Evaluation of patients with BPH

• Digital rectal examination (size not relevant)
• Urinalysis (pyuria, microhematuria)
• Urine Cytology (in patients irritative LUTS)
• Prostate Specific Antigen (PSA)
• Urine Flowmetry
• U/S KUB post void residue estimation

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Management Options for patients with BPH

• Medical therapy
• Instrumental (minimally invasive) therapy
• Surgical therapy

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Medical Therapies for BPH is the first line of
management of patients with symptomatic BPH
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Medical Therapies for BPH

• 5 a reductase inhibitors
• Finasteride (Proscar).
• Alpha- blockers
• Trazosin (Itrin).
• Doxazosin (Cardura).
• Alfuzosin (Xatral).
• Tamsulosin (Flomax, Omnic).

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Finasteride (Proscar).

• 5 a reductase inhibitors offer medical
  prostatectomy.
• Need 6/52 for patients to realize benefits.
• Valuable in large prostate gt 50 gms.
• Adverse effects
• Erectile dysfunction.
• Retrograde ejaculation.
• Teratogenic effects on Fetus ?
• Alters PSA levels.

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Alpha- blockers

• Alpha- blockers act on a-receptors in the BN
  Prostatic capsule.
• Rapid onset of action (within 2/52).
• Enhances sexual function ??
• Adverse effects
• Postural Hypotension.
• Retrograde ejaculation.

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Frequency of Sexual Intercourse per Month in Men
50-80 years
8.6
N12,815
5.7
4.9
4.0
3.7
1.7
PaoloEAU,Birmingham 2002
17
Percentage of Men Aged 50-80 Years No or Net
reduced Semen
89
N11,063
78
64
47
37
18
Paolo, EAU Birmingham 2002
18
Effect of Alfuzosin on the number of erections
induced by Apomorphine
Number of Erections
McKenna EAU, Birmingham, 2002
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Which Alpha- blocker ?

• Efficacy (Uro-selectivity ?)
• Dosing
• Single dose / Day
• No need for titration
• Minimal side effects
• Postural hypotension
• No retrograde ejaculation
• Cost of the treatment

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Minimally Invasive Therapies for BPO

• TUIP (Incision)
• Prostate balloon dilatation
• Urethral (prostatic) stents
• Hyperthermia
• Cryosurgery
• TUNA
• Laser devices

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Surgical Therapy for BPO

• Based on removal debulking of the obstructing
  prostatic adenoma, indicated in
• Failed medical treatment
• Complications
• Urinary retention.
• Renal back pressure changes.
• Hematuria.
• Large vesical stones.

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Surgical Therapy of BPO

• Open prostatectomy
• Transurethral prostatectomy
• TURP (Resection)
• TUVP (Vaporization)
• TUVRP (Vaporization-Resection)

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Transurethral resection of the Prostate (TURP)
using a standard wire loop and electrosurgical
unit is still regarded as the Gold Standard in
the treatment of men with BPO
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Morbidity associated with TURP

• Bleeding
• TUR syndrome (Low serum sodium)
• Infection
• Urinary incontinence
• Erectile dysfunction.

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Transurethral Vaporization Resection
Prostatectomy (TUVRP)

• Thick Loop (Resection)
• Augmented Electocutting energy (Electrovaporizatio
  n)
• TUVRP TURP TUVP
• Technique of operation!

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TUVRP

• TUVRP improves safety of transurethral
  prostatectomy and has the potential to reduce the
  main 2 morbidities that are associated with
  standard TURP namely bleeding and electrolyte
  disturbances.

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TUVRP

• The shorter post operative catheterization time
  that is noted following TUVRP is clinically
  significant considering the demand for lower
  morbidity profiles and hospitalization time by
  the patients and health care providers

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Conclusions

• Symptomatic BPH affects men over 40 years of age
  and erodes their quality of life

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Conclusions

• Pre treatment evaluation of patients is necessary
  to rule out other pathology that needs a
  different therapeutic approach

30
Conclusions

• Alpha- blockers should be the first line of
  treatment in every patient that is presenting
  with BPH with the aim of restoring quality of
  life and Sexual function

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Conclusions

• The Alpha-blocker of choice should be
  efficacious, once daily dose (with no titration),
  No sexual adverse effects and cost effective

32
Conclusions

• Patients that fail medical treatment or develop
  complications related to BPH should be referred
  to the Urologist for further work-up and
  interventional managment

33
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