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Medical Management of BPH

Medical Management of BPH

Medical Management of BPH
Symptoms caused by BPH
As the prostate gland enlarges in size it increases the urethral resistance to flow of urine from the bladder, this causes compensatory changes in bladder function resulting in following signs and symptoms
Increased urinary frequency
Urinary urgency
Nocturia( getting up at night more frequently to pass urine)
Poor urinary stream/ flow
Straining to pass urine
Intermittency
Sense of incomplete bladder emptying
What will happen if we do not treat BPH
It has been studied in several studies and clinical trials that there is worsening of urinary symptoms and BPH with time. The consequences of untreated BPH are
Bothersome urinary symptoms as listed above Urinary incontinence
Sudden onset urinary retention
Recurrent UTI ( urinary tract infection)
Hematuria (Blood in urine)
Bladder stones
Bladder decomposition / bladder failure
Renal failure ( renal insufficiency)

Evaluation and investigations
Detailed medical history
All patients with urinary symptoms should be asked detailed medical history to assess the severity of symptoms, to exclude other medical and surgical conditions can can produce same symptoms as BPH ( history of diabetes, nervous system disease like stroke, parkinsonism , dementia, disc prolapse, previous spine surgery, history suggestive of urethral stricture, previous medication history.
Physical examination
It includes looking for palpable bladder, metal stenosis, and urethral mass or indurations
Digital Rectal Examination
THE urologist inserts a lubricated gloved finger into the patients rectum and palpates/ feels the prostate gland.DRE assess
Approximate size of prostate gland
Presence of prostatic nodules or indurations suggestive of prostate cancer

Investigations
Urine analysis it excludes urinary infection as a cause of patient symptoms
PSA ( prostate specific antigen) PSA is a blood marker for prostate cancer. It may be elevate in prostate cancer, BPH or prostate infections. An elevated PSA needs further evaluation.
Kidney function tests
Ultrasonography it assess the size of prostate, bladder volume, bladder wall thickness , presence of associated bladder stones, diverticula, back pressure changes produced in kidney( hydronephrosis) produced by BPH
POSTVOID RESIDUAL URINE VOLUME. It is the volume of urine remaining in the bladder immediately after urination. High PVR indicates failure of medical therapy and watchful waiting.
Uroflometry it is a non invasive test and involves the electronic recording of urine flow rate throughout the act of urination. Flow rate measurements are inaccurate if patient passes less than 125 to 150 ml of urine.

WHAT ARE INDICATIONS OF DOING A URODYNAMIC STUDY IN BPH
Very young patients with LUTS ( lower urinary tract symptoms)
Normal flow rates but bothersome symptoms
History of neurological diseases known to affect bladder or sphincter function
Failed previous surgical treatment
Very high PVR

TREATMENT OF BPH
MEDICAL MANAGEMENT
The ideal candidates for medical management are those who have bothersome symptoms affecting the quality of life. It needs lifetime commitment to medical therapy
MEDICAL THERAPY
Alpha – adrenergic blockers 5 aplhareductase inhibitors Combination therapy Phosphodiesteraseinhibotors
Tamsulosin0.4mgFinestride 5mg Alpha-blockers+ 5 alpha reductaseTadalafil 5 mg
Silodosin 4mg& 8mgDutasteride 0.5mg inhibitors Alfuzocin 10mg

Side effects of Alpha blockers
Dizziness
Asthenia
Postural hypotension
Rhinitis & nasal stuffiness
Retrograde ejaculation
Floppy iris Syndrome

Side effects of 5 alpha reductase inhibitors
Loss of libido
Impotence
Ejaculatory disturbances

Side effects of phosphodiesterase inhibitors
Flushing
Headache
Hypotension
Rarely allergic reaction/ flu like symptoms

Treatment Algorithm
SURGICAL TREATMENT
SURGICAL OPTIONS FOR BPH
LASER PROSTATECTOMY
HOLEP (Holmium laser nucleation of prostate)
Green light laser prostatectomy
Diode laser prostatectomy
Thulium laser prostatectomy
TURP (Transurethral resection of prostate)
Open prostatectomy (rarely done)
What are indications of prostate surgery
Failure of medical therapy
Refractory urinary retention (urinary retention with failed catheter free trial)
Recurrent urinary infections
Bladder stones
Recurrent hematuria - gross
Renal insufficiency
Back pressure changes in Urinary bladder and Kidneys

Appointment Description

Medical Management of BPH
Symptoms caused by BPH
As the prostate gland enlarges in size it increases the urethral resistance to flow of urine from the bladder, this causes compensatory changes in bladder function resulting in following signs and symptoms
Increased urinary frequency
Urinary urgency
Nocturia( getting up at night more frequently to pass urine)
Poor urinary stream/ flow
Straining to pass urine
Intermittency
Sense of incomplete bladder emptying
What will happen if we do not treat BPH
It has been studied in several studies and clinical trials that there is worsening of urinary symptoms and BPH with time. The consequences of untreated BPH are
Bothersome urinary symptoms as listed above Urinary incontinence
Sudden onset urinary retention
Recurrent UTI ( urinary tract infection)
Hematuria (Blood in urine)
Bladder stones
Bladder decomposition / bladder failure
Renal failure ( renal insufficiency)

Evaluation and investigations
Detailed medical history
All patients with urinary symptoms should be asked detailed medical history to assess the severity of symptoms, to exclude other medical and surgical conditions can can produce same symptoms as BPH ( history of diabetes, nervous system disease like stroke, parkinsonism , dementia, disc prolapse, previous spine surgery, history suggestive of urethral stricture, previous medication history.
Physical examination
It includes looking for palpable bladder, metal stenosis, and urethral mass or indurations
Digital Rectal Examination
THE urologist inserts a lubricated gloved finger into the patients rectum and palpates/ feels the prostate gland.DRE assess
Approximate size of prostate gland
Presence of prostatic nodules or indurations suggestive of prostate cancer

Investigations
Urine analysis it excludes urinary infection as a cause of patient symptoms
PSA ( prostate specific antigen) PSA is a blood marker for prostate cancer. It may be elevate in prostate cancer, BPH or prostate infections. An elevated PSA needs further evaluation.
Kidney function tests
Ultrasonography it assess the size of prostate, bladder volume, bladder wall thickness , presence of associated bladder stones, diverticula, back pressure changes produced in kidney( hydronephrosis) produced by BPH
POSTVOID RESIDUAL URINE VOLUME. It is the volume of urine remaining in the bladder immediately after urination. High PVR indicates failure of medical therapy and watchful waiting.
Uroflometry it is a non invasive test and involves the electronic recording of urine flow rate throughout the act of urination. Flow rate measurements are inaccurate if patient passes less than 125 to 150 ml of urine.

WHAT ARE INDICATIONS OF DOING A URODYNAMIC STUDY IN BPH
Very young patients with LUTS ( lower urinary tract symptoms)
Normal flow rates but bothersome symptoms
History of neurological diseases known to affect bladder or sphincter function
Failed previous surgical treatment
Very high PVR

TREATMENT OF BPH
MEDICAL MANAGEMENT
The ideal candidates for medical management are those who have bothersome symptoms affecting the quality of life. It needs lifetime commitment to medical therapy
MEDICAL THERAPY
Alpha – adrenergic blockers 5 aplhareductase inhibitors Combination therapy Phosphodiesteraseinhibotors
Tamsulosin0.4mgFinestride 5mg Alpha-blockers+ 5 alpha reductaseTadalafil 5 mg
Silodosin 4mg& 8mgDutasteride 0.5mg inhibitors Alfuzocin 10mg

Side effects of Alpha blockers
Dizziness
Asthenia
Postural hypotension
Rhinitis & nasal stuffiness
Retrograde ejaculation
Floppy iris Syndrome

Side effects of 5 alpha reductase inhibitors
Loss of libido
Impotence
Ejaculatory disturbances

Side effects of phosphodiesterase inhibitors
Flushing
Headache
Hypotension
Rarely allergic reaction/ flu like symptoms

Treatment Algorithm
SURGICAL TREATMENT
SURGICAL OPTIONS FOR BPH
LASER PROSTATECTOMY
HOLEP (Holmium laser nucleation of prostate)
Green light laser prostatectomy
Diode laser prostatectomy
Thulium laser prostatectomy
TURP (Transurethral resection of prostate)
Open prostatectomy (rarely done)
What are indications of prostate surgery
Failure of medical therapy
Refractory urinary retention (urinary retention with failed catheter free trial)
Recurrent urinary infections
Bladder stones
Recurrent hematuria - gross
Renal insufficiency
Back pressure changes in Urinary bladder and Kidneys

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