G

For patients with mild symptoms, which the patient does not consider to be bothersome, watchful waiting is a reasonable approach to treatment. The patient is instructed to schedule return visits to the clinician every 3 to 6 months. At each visit, the patient's symptoms are reassessed using the AUA Symptom Scoring Index, and results are compared to baseline (Table 52-1). In addition, the patient is educated about avoiding factors that worsen obstructive and irritative voiding symptoms (Table 52-4). The DRE is repeated annually. If the patient's symptoms are unchanged, then watchful waiting is continued. If the patient's symptoms worsen, then specific treatment is initiated.1

Table 52-2 Objective Tests Used to Assess the Size of the Prostate and Complications of BPH

H<>w the Teft lj Pertornied

MmmjilTert de-suit

Test fifsult in hrthnti With BPH

DUE of the pios=a1e

PeaV and n*=an

Ljir.iiy flry,v rate

Urinalysis

PfostaTe needle Uiup4y

Pvoiti»iipil|M(W(f thrcvgli (hernial mt>;oia; tlw physician inserts aci indes linger into the ixnienriiea^ Pilient dtiiks water until bladde< e full: parent MApii» W^ddei. volume if urine outisil jnd timeioempny the bladder are nteasured: the Ikw rate (jnL/i is calculated Measurement of unrve left In rtv*hlacJdef after |Ikl pitlkfir hB 0*d TO titiffly Cul hii bladder: iswwed by tusthnl catheiefiMtbxi c* ultrasonography Midsneam urine is analyzed (iilcrcricopocallyfcir white blood cells and bacleria

Transrectal^', 4 bropsy raedte is inset Ted into tfh.1 Cfoitatt1; tissue iüfc ii stnt ljua (Hiliokiflüt ftx ariilyiü Bfcod tes1 Iot lhis chemical which ¡5 secreted by The piosiate

Pwtane- ii soft-synvmejvic, mobile, siae is 15-20 cj «0,5-0.7 «> Peak and mean urinary flow lateareat least ¡0 mLA

FVB should be 0 ml

Lrlne should Jiave no wimp ceils ar bacteria in it

A noiirwil prostate shot rid haw.'riowfck.'nu.-ol KW ua iifostare ciricef liiUhan A ng/mL mt^L)

itosMte ii enlü!)«). nnoie thjn M g (Q.5 oil no aieas of ¡niluralon or noAiUiity Peak and mean urinary (taw rates are lew Ihjn 10 mLA

PVftgieaiec than 50-ml ts a significant aiinniAfnuhtd urine; rt« a «sixüted Mth 1« iii lent urinaiy tract infection Ur<ve wilt: white blood cets aro bactena rs suggestive of infliicnmotion iinrl "r-loctionc If positive, urine is seni 1oi boctei ologic culture The biopsy is rcmiistent with fif'H

A P5A gieatei than 1.5 n^mL (I S nyg.'I.J Is a surogate-mater lor an enlarged prostate Renter th.m jQip (105 qvl

I il-!, 1: ::! il rfli E,»l iv !;VR. px -<-"vi 11:1 ri "Sjii:j,il ueir>1 tokjrTn; P^A, |:: = 1.1= ■ ',fIii .lriEi: |i 1 ■

Table 52-3 Staging the Severity of BPH Based on AUA Symptom Score and Example Signs of Disease

AUA Symptom Score

Signt o1 Discaid

Mwftrate Severs

G'cj'lv than ot equal Id 20

Enlarged pmjstaie on DRE. peak urinary flow rate less than oreqMal la lOnslft

All of the ¿bone, i'vh Qie-ste» Than 50 mL, tiiuii^

>11 of Iho ¿bave pkis-onu-cx moitf coniplicaljo'isaf BPH

AUA, Attil-m n^ijrt Lkfloykol BPIL benign pioiljfk typ&fltitt; DR[. dig 1jI n.t(jl gtinfclMt, pu^lvQid rciVAjyl urine vokjiix:

Tlii- AllA ^yrYiptinTi iiO^^ fCKirt^ QA ii-i^ft iliiTil IjrtiiWllfi^Ii* PiriVyiftQ Ifi^lJeiVn inrerrYiine(Vy. n^IVy, wft5V Hii'Wi, ^trairtirtiji ilVj nocturia) and asks that ihe patlem guamlfy the se^ef ity of hit oorrplalnti on a Kale of 0 t» 5. Thus, the More can fange fiom i to 3 J.

AUA, Attil-m n^ijrt Lkfloykol BPIL benign pioiljfk typ&fltitt; DR[. dig 1jI n.t(jl gtinfclMt, pu^lvQid rciVAjyl urine vokjiix:

Tlii- AllA ^yrYiptinTi iiO^^ fCKirt^ QA ii-i^ft iliiTil IjrtiiWllfi^Ii* PiriVyiftQ Ifi^lJeiVn inrerrYiine(Vy. n^IVy, wft5V Hii'Wi, ^trairtirtiji ilVj nocturia) and asks that ihe patlem guamlfy the se^ef ity of hit oorrplalnti on a Kale of 0 t» 5. Thus, the More can fange fiom i to 3 J.

Table 52-4 Drugs That Can Cause Irritative or Obstructive Voiding Symptoms

Phnrmicalogkc Cl4t$

Eicampt* Drug i

Mtchanism nt Elf ect

Androgens

Testosierone

Simu lane prostate enlargement

O'Adrurwgit. Jifonis-K

PtitTivlfptiNrn', püudoophixirim:

Stimulate onnriac Lion of [foslarit and WüMtf

neiV iiTc»rh niuiile

fl«1nhühnoftfc ageoü

Antihistamines. pheflolhiazinos, Iricyclk:

0loct bladder detiusi» muscle conliaclion.

an(icli.Tfn5an|v.jrHi[>.ni^in!onijri agents

Ttiiieby jinfMiring Jjladdit (.Tnf^yinri

Ohinelta

Thi*/jrteft dnivfiti, loop diureiirt

froducft- polyuria

^^ For patients with moderate to severe symptoms, the patient is usually offered drug treatment first. a-Adrenergic antagonists are preferred over 5a-reductase inhibitors because the former have a faster onset of action (days to a few weeks) and improve symptoms independent of prostate size. 5a-reductase inhibitors have a delayed onset of action (i.e., peak effect may be delayed for up to 6 months) and are seldom effective in patients with smaller size prostate glands (less than 30 g or 1.05 oz). Drug treatment must be continued as long as the patient responds (Table 52-5 ).10

Table 52-5 Comparison of a-Adrenergic Antagonists and 5a-Reductase Inhibitors for Treatment of BPH

Ch>nct*risik

n-Adrenergic AnTnguniKf

ScrReclufliie IplhÄJttort

Hsiao«* prostatic WKöih muscle

Ho

Rocluoei i'nc ol enbt^ed prostate

Ho

tte

Useful in paiiflmi wiih enlaged pjwtai«

Ha tJtaks ¡ndtipündem of the sine aS Ihe premie}

ts«

Efficacy in (elieviny voiding symptoms and 1 kiw (MC

+

Freqjuency of daily dosing

Once of 1wce doily, depending on 1 hi; agent and (fw dosage for mulalkm

Cnee dally

l>iquiioiiii*"i fcn urj riCkKifti of dose

Yes (for Tpfaiosin arid draarosin inrnneiftan?-releasejfc No (for alfurosin or sAkJcsii possibly fof doxazosin ijneinded Mease and LirnniliHiflJ

Mo

IVakonset of action

Days- G weeks, depend*vcj an need for dose 1i(ra1 on

t months

IXtnftnv« P5A

MO

Tftri

Canhovasculaf ad«"rse effects

Yes

No

DiuQ-irVJuCtd WWJiJl dyifurlition

IjiiuiatkKi diwdert

Deowsed iiUido.iir«Tiie dysfunction, ejaculation dlitmdef;

P5A, pfoitate-tpecifrc amigefi

P5A, pfoitate-tpecifrc amigefi

For patients with complications ofBPH disease (e.g., recurrent urinary tract infection, urosepsis, urinary incontinence, refractory urinary retention, chronic renal failure, large bladder diverticuli, recurrent severe gross hematuria, or bladder calculi secondary to prolonged urinary retention), surgery is indicated. Although it is potentially curative, surgery can result in significant morbidity, including erectile dysfunction, retrograde ejaculation, urinary incontinence, bleeding, or urinary tract infec-tion.12 The gold standard is a prostatectomy, which can be performed transurethrally or as an open surgical procedure, which can be performed suprapubically or retrop-ubically. To avoid complications of prostatectomy, minimally invasive surgical procedures, such as transurethral incision of the prostate, transurethral needle ablation, or

10 12 13

transurethral microwave thermotherapy, are options. ' ' Drug treatment is used in patients with severe disease when the patient refuses surgery or when the patient is not a surgical candidate because of concomitant diseases.

In the Multiple Treatment of Prostate Symptoms Study, it was found that selected patients with moderate to severe symptoms will benefit from a combination of a-ad-renergic antagonist plus 5a-reductase inhibitor drug therapy.14 Specifically, the use of doxazosin plus finasteride is more effective than doxazosin alone or finasteride alone in relieving symptoms, reducing the need for prostatectomy, and decreasing the incidence ofBPH complications in patients at highest risk of developing disease complications (i.e., those with prostate size of at least 40 g [1.4 oz]). Combination therapy is more expensive than monotherapy and also produces more adverse effects. Therefore, the clinician should discuss the advantages and disadvantages of combination therapy with a patient before deciding on a final treatment regimen.

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