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factors causing BPH
static factors- increased size due to androgen stimulation of epithelial tissue
dynamic factors- excessive alpha1 adrenergic tone
voiding/obstructive Sx vs storage/irritating Sx of BPH
voiding/obstructive: urine stream/flow rate diminished, urinary hesitance, straining, bladder feels “full” despite voiding
storage/irritating: urinary frequency, urinary urgency, bedwetting/nocturia
initial evaluation when doing pt assessment for BPH
history
focused examination and DRE
urinalysis (rule out UTI- looking for hematuria)
PSA (increased means enlarged or cancer)
what to consider when considering to treat BPH
symptom severity/effects on QoL
patient has a lot of input
complicating factors of BPH (refer to urology)
suspicious DRE
refractory retention
hematuria
bladder stones
renal insufficiency
recurrent UTI
elevated PSA
BPH diagnosis process
medical and symptom Hx
physicial exam
lab tests
patient perception
medical Hx
nonpharm measures BPH
fluid restriction before bedtime
avoidance of caffeine, alcohol, spicy foods
timed/organized voiding (bladder training)
weight loss
exercise
avoid certain meds, if possible diuretics, decongestants, antihistamines
manage constipation
first line Tx for individuals with BPH due to dynamic factors
non selective alpha adrenergic antagonist - terazosin, doxazosin, alfuzosin
selective- tamsulosin, silodosin (alpha1a)
what do alpha adrenergic antagonists improve
urinary flow rates, symptom scores (do not effect size or PSA)
decrease post void residual volume, increase urinary flow
how quickly do alpha adrenergic antagonists work
1-3wks
titration of non selective alpha adrenergic antagonists
titrate slowly and carefully- if several days of meds missed retitrate
why is prazosin not recommended in BPH
marked hypotensive effect
which non selective alpha adrenergic antagonist does not need to be titrated
alfuzosin
do selective or non selective alpha antagonists have more of a hypotensive effect
non selective
ae non selective alpha antagonisr
most common: dizziness, syncope, orthostatic hypotension, headache, asthenia
rare- intraoperative floppy iris syndrome
benefits of alfuzosin vs terazosin doxazin
uroselective- CV and hypotensive ae reduced and no dose titration needed
selective alpha antagonist ae
most common- drowsiness, nasal congestion, retrogade ejaculation and reduced ejaculate volume (silodosin>tamsulosin)
IFIS
allergy to be aware of with tamsulosin
sulfa- it contains a sulfa moiety (cross reactivity)
important drug interactions with alpha antagonists
metabolized by 3A4 therefore be careful with inducers/inhibitors
silodosin is a PGP substrate (careful combining with inhibitors)
cautious with PDE5i - severe hypotension - separate by 4hr (less likely with selective)
how/when to take alpha antagonists
doxasozin and terazosin HS
alfuzosin take with food
tamsulosin CR tabs with/without food
tamsulosin SR caps half hour after same meal each day
silodosin with food
tamsulosin vs silodosin crushing requirements
SR/CR tamsulosin swallow whole
silodosin capsule formulation may be opened and powder mixed in apple sauce
first line Tx for BPH due to static factors
5alpha reductase inhibitors (finasteride, dutasteride)
what does 5alpha reductase inhibitors improve
decrease PVR, increase urinary flow
decreased prostate size by 25% = decrease disease progression
decrease PSA by 50%
onset of 5alpha reductase inhibitors
6-12mo
does dutasteride or finasteride work faster
dutasteride
ae of 5 alpha reductase inhibitors
decreased libido
ED and other ejaculatory disturbances
muscle weakness (rare)
what does increased PSA indicate
BPH and/or prostate cancer
how often to test PSA with 5 alpha reductase inhibitors
baseline in those starting 5alpha reductase inhibitors
repeat in 6mo to establish new baseline + periodic thereafter
if PSA remains elevated a thorough investigation for prostate cancer should be performed
when is combo Tx indicated
symptomatic LUTS with prostatic enlargement (>30cc)
most prevalent ae with combo therapy
additive ae especially ejaculatory disturbances
when to use PDE5i BPH
LUTS/BPH + ED
regimen of PDE5i for BPH
tadalafil 5mg once a day regimen (vs prn_
when are antimuscarinic/B3 agonists use
commonly used for pts with overactive bladder- useful for individuals with BPH + storage Sx
who to use caution with B3 agonists in BPH
significant bladder outlet obstruction and/or elevated PVR
when to consider desmopressin
for men whos primary Sx is nocturia who do not respond to other Tx
monitoring of desmopressin specifically
sodium