BPH

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