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.
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Keyword: Benign Prostatic Hyperplasia
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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
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
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.
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.
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.
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.
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).
|8 – 20||Moderate|
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.
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 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 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).
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 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.
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.
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.
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.
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”.
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.
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.
After listening to this episode listeners will…
Dr. Reese has no relevant financial disclosures. The Curbsiders team has no relevant financial disclosures.
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