The Aging Prostate: Presentation, Diagnosis &

Management

Professor Riyadh F. Talic, MDProfessor of Urology & Andrology

College of Medicine, King Khalid University Hospital

And Consultant Urologist & Andrologist at Specialized Medical Center, SMC

Etiology of BPH

• Increasing Age

• Testosterone

Prevelance of BPH & Aging

60 yrs

50%

At 80 yrs

88%

Aging Prostate Terminology

• Benign Prostatic Hypertrophy (BPH)

• Benign Prostatic Obstruction (BPO)

• Lower Urinary tract symptoms (LUTS)

Benign Prostatic Hypertrophy

LUTS

BPH

Bladder dysfunction

Urinary Obstruction

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

Causes for Storage LUTS (Irritative LUTS)

• Urinary Outflow Obstruction

• Locally irritating pathology

• Neuro-vesical dysfunction

Cystitis

Tumors

Stones

Adverse effects of BPH

• Erodes Quality of Life

• Complications:– Urinary retention

– Recurrent hematuria

– Bladder stones

– Compromised renal function

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

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

Management Options for patients with BPH

• Medical therapy• Instrumental (minimally invasive)

therapy

• Surgical therapy

Medical Therapies for BPH is the first line of

management of patients with symptomatic BPH

Medical Therapies for BPH

• 5 α reductase inhibitors: – Finasteride (Proscar).

• Alpha- blockers:– Trazosin (Itrin).– Doxazosin (Cardura).– Alfuzosin (Xatral).– Tamsulosin (Flomax, Omnic).

Finasteride (Proscar).• 5 α reductase inhibitors offer medical

prostatectomy.• Need 6/52 for patients to realize benefits.• Valuable in large prostate > 50 gms.• Adverse effects:

– Erectile dysfunction.– Retrograde ejaculation.– Teratogenic effects on Fetus ?– Alters PSA levels.

Alpha- blockers• Alpha- blockers act on α-receptors in

the BN & Prostatic capsule.• Rapid onset of action (within 2/52).

• Enhances sexual function ??• Adverse effects:

– Postural Hypotension.– Retrograde ejaculation.

Frequency of Sexual Intercourse per Month in Men 50-80 years

0

1

2

3

4

5

6

7

8

9

50-59 yrs 60-69 yrs. 70-79 yrs.

IPSS=0 IPSS<7 <7IPSS>19 IPSS>20

8.6

4.95.7

3.7 4.0

1.7

N=12,815

Paolo:EAU,Birmingham 2002

Percentage of Men Aged 50-80 Years & No or Net reduced Semen

0

10

20

30

40

50

60

70

80

90

50-59 yrs 60-69 yrs 70-79 yrs

IPSS=0 IPSS>7 <7IPSS>19 IPSS>20

6478 89

18

3747

N=11,063

Paolo, EAU; Birmingham 2002

Effect of Alfuzosin on the number of erections induced by Apomorphine

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Apomorphine Apomorhine + Alfuzosin

Num

ber of E

rections

McKenna: EAU, Birmingham, 2002

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

Minimally Invasive Therapies for BPO

• TUIP (Incision)

• Prostate balloon dilatation

• Urethral (prostatic) stents

• Hyperthermia

• Cryosurgery

• TUNA

• Laser devices

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.

Surgical Therapy of BPO

• Open prostatectomy

• Transurethral prostatectomy– TURP (Resection)– TUVP (Vaporization)

– TUVRP (Vaporization-Resection)

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

Morbidity associated with TURP • Bleeding• TUR syndrome (Low serum sodium)

• Infection

• Urinary incontinence• Erectile dysfunction.

Transurethral Vaporization Resection Prostatectomy (TUVRP)

• Thick Loop (Resection)• Augmented Electocutting energy (Electrovaporization)• TUVRP = TURP + TUVP• Technique of operation!

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.

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

Conclusions

Symptomatic BPH affects men over 40 years of age and

erodes their quality of life

Conclusions

• Pre treatment evaluation of patients is necessary to rule out other

pathology that needs a different therapeutic approach

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

Conclusions

• The Alpha-blocker of choice should be efficacious, once

daily dose (with no titration), No sexual adverse effects and

cost effective

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