#148 Benign Prostatic Hyperplasia

April 29, 2019 | By Beth Garbitelli

Become a Prostate Pro with Dr. Adam Reese MD

This week we narrow in on the enlarging prostate and decipher the common issue of benign prostatic hyperplasia with Adam C. Reese MD, Associate Professor of Urology at the Lewis Katz School of Medicine at Temple University and Chief of Urologic Oncology at Temple University Hospital. Learn how to interpret the symptom profile for patients presenting with common urinary issues, what to feel for in the digital rectal exam, how to treat BPH, and when to refer.

ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST).

Keyword: Benign Prostatic Hyperplasia

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See you at SGIM 2019!

Find us in our red Curbsider’s t-shirts handing out Curbsiders and Kashlak stickers/patches at SGIM 2019 in Washington DC! We’ll be recording full length shows and daily recaps!

Credits

Written and produced by: Paul Williams MD

Hosts: Paul Williams MD, Matthew Watto MD

Images and infographics: Elena Gibson, Beth Garbitelli

Show Notes: Elena Gibson, Beth Garbitelli

Edited by: Matthew Watto MD, Chris Chiu MD

Guest: Adam Reese MD

Time Stamps

00:00 SGIM announcement

00:30 Disclaimer, intro and guest bio

03:20 Guest one liner, book recommendation, favorite failure and surgical M&M

10:56 Case of benign prostatic hyperplasia, defining terms and obstructive/voiding versus storage/irritative symptoms

16:11 IPSS score and evaluating symptoms

22:10 Digital rectal exam. Will this give any useful information?

26:55 Taking a history about BPH and some lifestyle modifications

29:20 Lab studies for urinary tract symptoms and interpreting PSA and free PSA

36:20 Initial therapy for BPH and managing patient expectations, alpha blocker side effects

39:25 Choice of agent and monitoring symptoms on therapy

42:25 Nonpharmacologic management of bladder complaints

45:10 Who and when to refer to urology

47:33 Counseling about use of 5 alpha reductase inhibitors, their side effects and is there a risk for high grade cancer?

52:35 Phosphodiesterase inhibitors for BPH symptoms

53:50 Urethral milking. NOT prostate milking

54:55 Desmopressin for nocturia

56:20 Take home points

59:03 Prostate volume and PSA

61:10 Outro

Benign Prostatic Hyperplasia Pearls

Not all urinary symptoms are due to BPH. Think about your patient’s demographics and keep your differential broad.

Symptoms experienced with BPH are classified as lower urinary tract symptoms (LUTS) and can be separated into obstructive-voiding and irritative-bladder storage symptoms.

Think critically about the constellation of symptoms as well as the patient’s quality of life concerns. These considerations will guide care.

PSA can be a valuable tool when used appropriately if you are educated on the potential pitfalls of testing.

If ever in doubt, urologists are always happy to see these patients! Referrals are indicated for persistent urinary symptoms after drug therapy, hematuria, a large nodule on prostate, high PSA, recurrent UTIs, or significant neurological symptoms.

BPH Show Notes

Clinical Case from Kashlak:

Kilgore Trout is a 63 year old male with type 2 diabetes, stage 3 chronic kidney disease, and hypertension. He is currently on metformin monotherapy. He reports tobacco use in the past. He decides to visit his primary care provider for urinary symptoms that have been going on for ‘a while’ including nocturia 3 times nightly, urinary hesitancy, a sensation of incomplete emptying, nd post-void dribbling.  He reports no burning, no blood in urine, no fevers, no chills. He is still working as a garbage truck driver but the urgency during the day is embarrassing for him and he has begun carrying a bottle, because sometimes during his routes he needs to pull over and find a space to relieve himself.

Benign Prostatic Hyperplasia vs. Prostatic Hypertrophy

Historically, the term benign prostatic hypertrophy was used, but from a pathologist’s histological perspective, these cellular changes are more correctly classified as a hyperplasia.  Hyperplasia is a proliferation of cells, whereas hypertrophy is an increase in the size of individual cells. The region of hyperplasia is the transition zone of prostate.

Symptom Evaluation

The preferred terminology for the cluster of symptoms experienced is not “BPH symptoms”, but lower urinary tract symptoms (LUTS). LUTS can be due to various causes and can be divided into more descriptive subcategories such as obstructive-voiding symptoms (weak stream, straining to void, hesitancy, intermittency of urinary stream, feeling of incomplete emptying, post-void dribbling) or irritative-storage symptoms (urinary frequency, urgency, incontinence, nocturia). Thinking about the symptom breakdown will assist with determining the differential diagnosis for this patient (ie: overactive bladder versus BPH) as well as tailor your medical intervention. Once a workup is complete and a BPH diagnosis has been confirmed, the symptoms can be referred to as LUTS due to BPH.  

IPSS

The International Prostate Symptom Score (IPSS), a validated questionnaire to assess severity, can be filled out by patient to assess the symptom profile (Barry 1992). An important part of IPSS relates to quality of life (“If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?”) as this can tailor how aggressively (if at all) the treatment should be approached.

Age is important. BPH incidence increases with age. According to the National Institutes of Health’s National Institute of Diabetes and Digestive and Kidney Diseases, BPH “rarely causes symptoms before age 40” and “affects about 50 percent of men between the ages of 51 and 60 and up to 90 percent of men older than 80.” For men younger than middle age, particularly if they only have irritative symptoms, bladder issues are more likely (Kaplan 1996,Nitti 2002).

IPSS Assessment

Will reducing thiazide or managing diabetes more closely improve symptoms without additional intervention?

Modification of diuretics/drug therapy for other conditions can improve the patients symptoms. Managing glycemic levels can also help. Often times, several different mechanisms contribute to a constellation of symptoms. Each exacerbating factor must be addressed separately.

How should we approach the digital rectal exam?

While it is not a perfect exam (indicated by studies showing discrepancies between prostate size estimated by rectal exam and actual prostate size), it can give the provider some general, important information.

Feel for size (eg big or “not that big”). And, identify any hardened nodules (indicative of malignancy) or irregularity in shape. The texture should be firm and rubbery with a groove, NOT soft/spongy or ‘rock’ hard (White 1990). The exam may reveal tenderness or elicit pain from patient. This may indicate acute prostatitis, but the patient often looks sicks and has other symptoms like fever, constitutional signs and leukocytosis.

Urinalysis

Urinalysis should be done to rule out UTI. Hematuria (blood in urine) necessitates a referral to urology when present.

The American Urological Association does not recommend checking creatinine in patients with LUTS and presumed BPH, although European Urological Association argues that it can be helpful since renal issues are not always apparent and therapy may increase renal side effects. It’s useful to check Creatinine if ultrasound shows hydronephrosis. BUT, this likely does not need to be done routinely.

PSA testing in Benign Prostatic Hyperplasia

PSA is an imperfect test for prostate cancer because BPH can also cause an elevated level. Low PSA could potentially rule out BPH. Percent Free PSA is an underutilized measure which helps differentiate PSA due to cancer vs BPH. While high % free PSA argues against cancer, low % free PSA is more consistent with prostate cancer (Pauler Ankerst J Urol 2016).

Approach to treatment of Benign Prostatic Hyperplasia

Alpha Blockers

Alpha blockers are first line therapy. They can be divided into selective (tamsulosin, silodosin)  versus non-selective (terazosin, doxazosin). Selective alpha blockers are less likely to cause orthostasis.  Concomitant use of phosphodiesterase inhibitors for erectile dysfunction (which is common in these patients) with non-selective alpha blockers can potentially lead to significant hypotension.

Lifestyle Modifications

Lifestyle modification suggestions include: caffeine avoidance, energy drink avoidance, alcohol reduction, nighttime fluid intake reduction, bathroom before bed, and double voiding (wait about 10 seconds after voiding and then try to void again) —Bradley 2017.

Follow Up Care and Next Line agents

Patient should return in a few months, unless they are severely bothered by symptoms. If irritative symptoms (nocturia, frequency, urgency, etc) are not improving, then overactive bladder may be present. In these cases, a trial of anticholinergic therapy can be considered. Conversely, if obstructive symptoms (weak stream, incomplete emptying, straining to void) and an enlarged prostate are present, a 5-alpha-reductase inhibitor (finasteride,dutasteride) may be indicated.

Phosphodiesterase inhibitors like tadalafil have a modest impact on treating LUTS and are rarely used (Dahm 2017). Other therapies are more effective, but tadalafil can be used in patients with mild LUTS and erectile dysfunction.

How do you tailor a patient’s expectations? And what side effects may they be concerned about?

Most people will see a benefit in about a week or so from an alpha blocker. 5-alpha-reductase inhibitors have a slower onset of action, taking up to a few months for full effect. Make sure to explain this longer timeline for 5-alpha-reductase inhibitors so patients do not become discouraged.

Alpha Blocker Side Effects

The dosing for both medication types is once daily, recommended in the evening due to the orthostatic hypotension side effect. These drugs can also interfere with ejaculatory function, leading to decreased or absent ejaculate. Floppy iris syndrome with tamsulosin therapy is a real concern and the patient’s ophthalmologist should be aware they are using this drug.

5 alpha reductase inhibitor side effects

The 5-alpha-reductase inhibitors can have more sexual side effects related to erectile dysfunction and can also cause gynecomastia. It is also notable that 5-alpha-reductase inhibitors will artificially lower the PSA value by about 50% (Gormley 1992). If screening for prostate cancer with PSA, the adjustment of doubling the value should be done. Research looking at the prevention of prostate cancer with 5-alpha reductase inhibitors identified reductions in the overall prevalence of prostate malignancies with the medication, but high-grade malignancies were more common (Thompson 2003, Wilt 2008)

What about pelvic floor strengthening? And urethral milking?

Pelvic floor strengthening is gaining in popularity and there’s a large benefit, especially for patients who experience urinary urgency under stress. There is less evidence that it may be helpful in patients fitting the profile for BPH, although it is something being considered.  

Urethral milking can help patients. You may counsel the patient to “gently squeeze the base of the penis after urinating and work [their] way outward to force urine out of the urethra”.

When should we refer?

If urinary symptoms persist after drug therapy, a referral is necessary and warranted. It especially makes sense if the symptoms persist after dual drug therapy. Other reasons for referral include: hematuria (which can indicate bladder stone or bladder cancer), a large prostate nodule, high PSA, recurrent UTIs and significant neurological pathology (spinal cord injury, neuromuscular disorders), which can manifest as similar urinary symptoms which should be dealt with by a urologist.

Goals and Learning Objectives

Goals

Listeners will be able to understand and implement the workup for benign prostatic hyperplasia, including relevant labs and the prostate exam, as well as construct a differential for other similar conditions.

Learning objectives

After listening to this episode listeners will…

1. Define Benign Prostatic Hyperplasia (BPH).
2. Address common prostate complaints and determine when necessary to refer to urology.
3. Describe and categorize lower urinary symptoms in men.
4. Utilize tests and labs for prostate condition management.
5. List pharmacological interventions for BPH and explain their mechanisms of action.
6. Counsel patients regarding BPH treatment side-effects.

Disclosures

Dr. Reese has no relevant financial disclosures. The Curbsiders team has no relevant financial disclosures.

Links from the show, plus some extras, to browse at your pleasure

1. Dr. Reese’s Pick of the Week: Sapiens: A Brief History of Humankind and Homo Deus: A Brief History of Tomorrow,  both by Yuval Noah Harari
2. International Prostate Symptom Score (IPSS) – a validated questionnaire to assess LUTS.
3. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition – Chapter 190 Prostate Examination
4. Videos in Clinical Learning – Digital Rectal Examination and Anoscopy – The New England Journal of Medicine
5. Digital rectal exam demonstration from BMJ Learning

References

Links have been included in body of text above

1. Barry MJ, Fowler FJ, Jr., O’Leary MP, et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. The Journal of urology. 1992;148(5):1549-1557; discussion 1564.[https://www-ncbi-nlm-nih-gov.ezproxy3.lhl.uab.edu/pubmed/1279218]
2. Prostate Enlargement (Benign Prostatic Hyperplasia). National Institute of Diabetes and Digestive and Kidney Disease (NIDDK). https://www.niddk.nih.gov. Updated September 2014. Accessed March 22,2019.
3. Kaplan SA, Ikeguchi EF, Santarosa RP, et al. Etiology of voiding dysfunction in men less than 50 years of age. Urology. 1996;47(6):836-839.[https://www.ncbi.nlm.nih.gov/pubmed/8677573]
4. Nitti VW, Lefkowitz G, Ficazzola M, Dixon CM. Lower urinary tract symptoms in young men: videourodynamic findings and correlation with noninvasive measures. The Journal of urology. 2002;168(1):135-138.[https://www.ncbi.nlm.nih.gov/pubmed/12050507]
5. Roehrborn CG, Girman CJ, Rhodes T, et al. Correlation between prostate size estimated by digital rectal examination and measured by transrectal ultrasound. Urology. 1997;49(4):548-557.[https://www.ncbi.nlm.nih.gov/pubmed/9111624]
6. Ahmad S, Manecksha RP, Cullen IM, et al. Estimation of clinically significant prostate volumes by digital rectal examination: a comparative prospective study. Can J Urol. 2011;18(6):6025-6030.[https://www.ncbi.nlm.nih.gov/pubmed/22166330]
7. White JM JR, O’Brien DP III. Prostate Examination. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 190. Available from: https://www.ncbi.nlm.nih.gov/books/NBK301/
8. American Urologic Association. Chapter 1: AUA Guideline on the Management of Benign Prostatic Hyperplasia (2003). Published 2003. Accessed March 23,2019. [https://www.auanet.org/Documents/education/Arc-BPH-Chapter1.pdf]
9. European Association of Urology. Guidelines on Benign Prostatic Hyperplasia. Updated February 2002. Accessed March 23,2019. [https://uroweb.org/wp-content/uploads/EAU-Guidelines-Bening-Prostatic-Hyperplasia-2002.pdf]
10. Gratzke C, Bachmann A, Descazeaud A, et al. EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction. Eur Urol. 2015;67(6):1099-1109.[https://www.ncbi.nlm.nih.gov/pubmed/25613154]
11. Bradley CS, Erickson BA, Messersmith EE, et al. Evidence of the Impact of Diet, Fluid Intake, Caffeine, Alcohol and Tobacco on Lower Urinary Tract Symptoms: A Systematic Review. The Journal of urology. 2017;198(5):1010-1020.[https://www-ncbi-nlm-nih-gov.ezproxy3.lhl.uab.edu/pubmed?term=28479236]
12. Dahm P, Brasure M, MacDonald R, et al. Comparative Effectiveness of Newer Medications for Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: A Systematic Review and Meta-analysis. Eur Urol. 2017;71(4):570-581.[https://www-ncbi-nlm-nih-gov.ezproxy3.lhl.uab.edu/pubmed/27717522]
13. Gormley GJ, Stoner E, Bruskewitz RC, et al. The effect of finasteride in men with benign prostatic hyperplasia. The Finasteride Study Group. N Engl J Med. 1992;327(17):1185-1191.[https://www.ncbi.nlm.nih.gov/pubmed/1383816]
14. Thompson IM, Goodman PJ, Tangen CM, et al. The influence of finasteride on the development of prostate cancer. N Engl J Med. 2003;349(3):215-224.[https://www-ncbi-nlm-nih-gov.ezproxy3.lhl.uab.edu/pubmed/12824459]
15. Wilt TJ, MacDonald R, Hagerty K, Schellhammer P, Kramer BS. Five-alpha-reductase Inhibitors for prostate cancer prevention. Cochrane Database Syst Rev. 2008(2):Cd007091.[https://www.ncbi.nlm.nih.gov/pubmed/18425978]
16. Try these techniques to relieve common urinary symptoms without medication. Harvard Men’s Health Watch. Harvard Health Publishing.https://www.health.harvard.edu/mens-health. Updated November 2013, Accessed March 22, 2019.

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