BPH

Obstructive vs Irritative symptoms

Obstructive	Irritative
physical blockage or narrowing of urethra from enlarged prostate	overactive bladder symptoms from irritation of bladder muscle
hesitancy	urgency
straining	frequency
weak urine stream	nocturia
post-void dribbling	bed or clothes wetting
bladder full after voiding
decreased bladder emptying

Dynamic vs Static Factors

Dynamic	Static
narrowing of the urethral lumen	enlargement of prostate gland
excess α-adrenergic tone in stromal tissue increasing smooth muscle tone and contraction of bladder neck in urethra	testosterone/DHT stimulation of epithelial tissue

Laboratory/diagnostic tests for screening

Lab Test	Results
American Urological Association	mild <7 moderate 8-19 severe 20+ questionnaire
Urinalysis	rules out infection/stones
Prostate Specific Antigen (PSA)	patients in 40+ years old with 10 year life expectancy normal < 1-1.5 ng/mL
Digital Rectal Exam (DRE)	assess size and shape of prostate normal <20 g
Transrectal Ultrasound (TRUS)	radiologic and imaging
Post-void Residual (PVR)	normal < 50 mL left in bladder post pee 300+ mL refer to urologist
Uroflowmetry	urine voided per sec

Medications that worsen BPH

Class	Examples	How
Sympathomimetics	decongestants (α1 adrenergic agonists) antihypertensives (α2 adrenergic agonists)	more contraction less flow
Opioids		increases sphincter tone increasing PVR
Diuretics	loop and thiazide	more urine increasing frequency and urgency
Anticholinergics	antihistamines tricyclic antidepressants antipsychotics muscle relaxants antispasmodics	less bladder contraction increases PVR
Testosterone Products		increase prostate growth

Explain the MOA of 5 α-reductase inhibitors, α1 adrenergic receptor antagonists, and PDE5 inhibitors

Class	MOA	best patients	Monitoring	Notes	Patient counseling
α1-Adrenergic Receptor Antagonists	smooth muscle relaxation of prostate bladder neck and urethra	reduces dynamic factors in moderate (AUA 8-19) symptoms	takes 1-6 weeks to see benefit of symptom relief lowest dose at night and increase weekly monitor BP and HR	a1A prostate and urethra desired effects a1B vascular smooth muscle may cause orthostatic hypotension or syncope a1D only bladder	Orthostatic Hypotension syncope/lightheadedness prevent by getting up slowly dangle feet before waking up or standing elevate head in bed move legs while standing avoid bending at waist Intraoperative floppy iris syndrome cataract surgery complication that can cause permanent vision loss Hypotension may need to switch from non-uroselective 2nd Gen to selective 3rd Gen Priapism rare but serious reaction seek PCP ASAP
5 α-Reductase Inhibitors	inhibit conversion of inactive testosterone to active dihydrotestosterone DHT	reduces static factors in moderate symptoms	best in patients with prostate 30+ g decrease PSA levels by 50% and prostate size by 25% over 6 months monitor PSA	correct PSA by doubling measured PSA after 6 months to approx true	Pregnancy category X pregnant women should not handle tables women should not touch fluid containing them ask doctor to order PSA level before starting Side Effects gynecomastia decreased libido erectile and ejaculatory dysfunction
PDE5 inhibitors	smooth muscle relaxation of prostate, bladder neck, and prostate urethra	reduce dynamic factors in moderate symptoms	monitor BP pulse and hearing	metabolized by CYP3A4 so avoid medications that are inhibitors G ❤ PACMAN	Do not take with nitrates both relax blood vessels so may drop BP too much and cause heart attack wait 48H before nitrates Side effects headache dizziness hearing loss impaired color discrimination

Compare the distribution of 5 α-reductase enzyme and α1-adrenergic receptors in BPH and how that corresponds to response in therapy

Normal Prostate	BPH
2 stromal to 1 epithelial	5 stromal to 1 epithelial
more 1α than 5α (DHT)	even more 1α than 5α (DHT) more narrowing

Nonpharm

Healthy Lifestyle

Patient Education

low-fat diet with high fruits and vegetables

restrict fluid close to bedtime

empty bladder often while awake

regular physical exercise

stop smoking

minimize caffeine, alcohol,

drugs that worsen voiding symptoms

Match brand/generic and class of drugs used for treatment of BPH

Drug (Generic)	Brand Name(s)	Class	Dose	Other
Finasteride	Proscar, Propecia	5α-reductase inhibitor	5 mg PO Qday	inhibit type 1 sebaceous glands FDA alopecia
Dutasteride	Avodart	5α-reductase inhibitor	0.5 mg PO Qday	inhibit type 1 and 2 sebaceous glands and prostate and genital tissue tamsulosin combo Jayln
Tamsulosin	Flomax	3rd Gen α1A-adrenergic antagonist	0.4 or 0.8 mg Qday	off-label nephrolithiasis Caution in sulfa allergy take 30 min after a meal do not crush or chew
Silodosin	Rapaflo	3rd gen α1A-adrenergic antagonist	8 mg Qday	if CrCl 30-50 mL/min or hepatic impaired 4 mg If CrCl < 30 mL/min contraindicated
Prazosin	Minipress	2nd Gen α1-adrenergic antagonist	0.5-5 mg BID	FDA HTN off-label BPH
Terazosin	Hytrin	2nd Gen α1-adrenergic antagonist	1-20 mg Qday	FDA also HTN
Doxazosin	Cardura	2nd Gen α1-adrenergic antagonist	1 - 8 mg Qday	FDA also HTN XL OROS ghost tablet in poop
Alfuzosin (most uroselective)	Uroxatral	2nd Gen α1-adrenergic antagonist	10 mg Qday	do not crush or chew prolongs QT interval bradycardia caution in CrCl < 30 mL/min
Tadalafil	Adcirca	PDE5 inhibitor	40 mg PO Qday	BPH and pulmonary HTN
Tadalafil	Cialis	PDE5 inhibitor	5 mg PO Qday	BPH and erectile dysfunction

List treatment options in BPH based on severity of symptoms (According to AUA guidelines)

Uroselective and their advantage over non-uroselective agents

Uroselective (α1A selective): Tamsulosin, Silodosin, Alfuzosin (most uroselective among 2nd gen)
Advantage: Lower risk of orthostatic hypotension and cardiovascular side effects compared to non-uroselective agents.

Differentiate between different pharmacological classes used for treatment of BPH in terms of adverse effects, onset, effect on PSA/prostate size, monitoring parameters, and halting disease progression

Class	Onset	Prostate Size/PSA	Adverse Effects	Disease Progression	Monitoring
α1-blockers	1–6 wks	No effect	Orthostatic hypotension, dizziness, IFIS, priapism	No	BP, HR, symptoms
5α-reductase inhibitors	6–12 mo	↓ size, ↓ PSA	ED, decreased libido, gynecomastia	Yes	PSA, DRE
PDE5 inhibitors	4 wks	No effect	Headache, flushing, hypotension	No	BP, symptoms

Describe the role of anticholinergics/antispasmodics in BPH (side effect vs. therapeutic use)

Drug	Brand	Formulation	Dosing
Darifenacin	Enablex	Oral tablet	7.5-15 mg Qday
Fesoterodine	Toviaz	Oral tablet	4 - 8 mg Qday
Solifenacin	Vesicare	Oral tablet	5-10 mg Qday
Oxybutynin	Ditropan Ditropan XL Oxytrol Gelnique	Oral tablet/syrup Oral tablet TD patch Topical gel	5-10 mg BID/TID 5-30 mg Qday 1 patch Q4D 3 pump Qday
Tolterodine	Detrol Detrol LA	Oral tablet Oral Capsule	2 mg BID 4 mg Qday
Trospium	Sanctura Sanctura XR	Oral tablet Oral capsule	20 mg BID 60 mg Qday

Therapeutic use: For patients with mixed symptoms of BPH and overactive bladder (OAB), anticholinergics or beta-3 agonists may be added. block receptors to inhibit contraction of the detrusor muscle
Side effect: Anticholinergics can worsen urinary retention and are generally avoided unless OAB symptoms predominate. should not be used in patients with PVR > 250 mL