PHRM 825 Lecture 49- Mens Health Part 2

normal size gland <20 g

surrounds the proximal urethra

prostate gland

around what age is growth of the prostate common

age 40

which receptors in the prostate are stimulated by NE to contract and narrow the urethra

alpha 1 adrenergic receptors

converts testosterone to DHT

responsible for prostate enlargement and growth

type II 5-alpha reductase in the prostate gland

obstructive symptoms of BPH

decreased force of stream

hesitancy to initiate urinating

strain or push to urinate

terminal dribbling

intermittency

irritative symptoms of BPH

nocturia, urinary frequency, urgency, dysuria, bladder pain, incontinence, QOL

what constitutes nocturia in men with BPH

2 or more voids per night

how is the diagnosis of BPH made

clinical symptoms + digital exam

measuring flow rate

measuring residual volume (bladder scan)

AUA score

complications of BPH

chronic renal failure

overflow urinary incontinence

recurrent UTIs

diminished QOL

treatment of moderate BPH with erectile dysfunction

a adrenergic antagonist, phosphodiester inhibitor, or both

treatment of moderate BPH with small prostate and low PSA

a adrenergic antagonist

treatment of moderate BPH with large prostate and increased PSA

5a reductase inhibitor OR 5a reductase inhibitor + a adrenergic antagonist

treatment of moderate BPH with predominant irritative voiding symptoms

a adrenergic antagonist + anticholinergic agent

treatment of severe BPH with complications

minimally invasive surgery or prostatectomy

goals of therapy for BPH

control symptoms

decrease AUA score by at least 3 pts

prevent complications

what drug class should be avoided for all patients with BPH

drugs with strong anti-cholinergic properties (antihistamines, antidepressants, anti-muscarinics)

which patients should anti-muscarinics especially be avoided in

with post void residual >200 ml and/or max urine flow rate of <5 ml/sec

what can be used for self treatment of mild BPH

CAM therapy (Saw Palmetto)

moderate BPH treatment options

non drug measures

alpha blockers +/-

hormone therapy

PDE inhibitors

relaxes smooth muscle tone of prostate gland and bladder neck

does NOT reduce size of prostate gland

onset in 1-6 weeks

decreases AUA by 30-40%

alpha-1a adrenergic blockade

which two alpha-1 adrenergic blockers are older agents used for HTN

terazosin and doxazosin

which alpha-1 adrenergic blockers are more selective in urinary tract

Tamsulosin (Flomax), Alfuzosin (Uroxatrol), Silodosin (Rapaflo)

side effects of a1 adrenergic blockers

dizziness

headache

fatigue

orthostatic hypotension

retrograde ejaculation (decreased volume)

which a1 blocker is most commonly used

Tamsolusin (Flomax)

What should you inquire about with patients when first filling Flomax prescription?

Cataracts- intraoperative floppy iris syndrome has been observed during cataract surgery

indicated if patient also has ED

effectiveness similar to a antagonist

relaxes smooth muscle tone of prostate gland and bladder neck

PDE inhibitor

what is an example of a PDE inhibitor and when is it contraindicated

Tadalafil 5 mg daily

2.5 mg if CrCl 30-50 ml/min

do NOT use if CrCl <30 ml/min

hormonal therapy for BPH

decreases DHT production which decreases size of prostate by 20-25%

men with prostate >40g benefit most

5-alpha reductase inhibitors

how long can the onset of action for 5-alpha reductase inhibitors be

as long as 6 months- also initiate alpha antagonist

examples of hormonal therapy drugs

Finasteride (Proscar)- 5 mg PO daily

Dutasteride (Avodart)- 0.5 mg PO daily

side effects of hormonal therapy

breast enlargement

ejaculation disorder

breast tenderness

effectiveness of hormonal therapy

decreases PSA by 50% in 6 months

generics of Jalyn combination therapy

dutasteride + tamsulosin

what does finasteride + tadalafil treat

BPH + ED

what does tamsulosin + tolterodine treat

BPH + OAB

most used minimally invasive therapy for severe BPH

transurethral microwave thermotherapy (TUMT)

most used invasive surgical therapy for BPH

transurethral resection of the prostate (TURP)

used to induce prostatic atrophy in small group of patients who were not surgical candidates

botox injections