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BPH – Case Studies & FAQs
Dr Clarence Lei Chang Moh, Consultant Urologist
BORNEO REGIONAL UROLOGY WORKSHOP, Kota Kinabalu, 9-10 July 2011
Mr C C K, 76 years old, retired Govt teacher(P.B.L. case scenario)
• 16.12.09: Referred by nephrologist for intermittent giddiness, “possibly due to prostate medication”.
• Nocturia 3x and consulted family doctor. PSA 0.7 (31.8.08)
• Started on “Hytrin 2mg ON” • Patient seen in Cardiac Clinic, SGH for ? irregular
heart rhythm and on Cardiprin.• Managed to get Cardiologist to continue urological
medication and was given Terazosin 2 mg (RM1 vs 70s).
What are the causes of nocturia?(Dr Lei N2X)
1. Prostate
Women also reports nocturia
- give prostate medications ?
What are the causes of nocturia?(Dr Lei N2X)
1. Prostate problem - incomplete bladder emptying, requiring multiple voiding:
2. Bladder problem:
- OAB, overactive bladder, treat with anti-cholinergic
- Decreased bladder compliance with age: less fluid pm
Bladder irritation:
(a) UTI: urine test, antibiotics
3 . Volume: nocturnal polyuria due to:
(a) Diabetes mellitus (up to 20% - MAJOR problem)
(b) Heart failure: lasix am, nap pm
(c) “Diabetes insipidus” Polyuria – Minirin (taxi driver – CPM)
4. Brain: Poor sleep/anxiety
5. Combination !! – treat one by one
Assessment of nocturia, given prostate medications
• If prostate is causing obstruction, poor urine flow.• urine flow will be good only vol >150 cc. • (the patient said his urine flow is very good in the
morning with some urgency)
• Patient probably did not have BOO from prostate and Hytrin or similar inappropriate. Moreover, the alpha-blocker may contribute the giddiness.
obstructed
FOC – at campaigns
Do u observe others? : flow/penis
What further specialised investigations?
1. PSA, (PSA> 1.5 = enlarged = Avodart). • Uroflowmetry, Urology Clinics,
(max 15 ml/s VV 150 ml)
PSA 0.15
HPCRAUR
Other α-blockers
• α blocker - prazosin 1-2 mg ON, bd (also BP)• selective α1 blocker
– Terazosin 1- 2- 5mg ON (Titrate!) (“Hytrin”)– Doxazosin XL 4 mg ON (“Cardura”)
• Uroselective α1 blocker– Tamsulosin (“Harnal”)– Alfuzosin XL (“Xatral”)
Barkin J. Canadian Journal of Urology.2008;15(6) 4353-4358
Urine retention
• (case of Australian Immigration; pc, palpable bladder, hydro)
A.Catheter? in /out/admit
B.TWOC
C.? TWOC with meds
D.Catheter admit; TURP
E.Catheter TURP 1 week
Cx BPH: how common?• Thirds: stable, better, progress
• Retention: acute, chronic (detrusor failure)
• UTIs
• Stones
• OAB, overactive
• Obstructive Uropathy
• Admission: fever, bleed, diuresis or hydro
• OPERATION (9%)
Ball AJ, Fenelay RCL, Abrams PH: The Natural History of Prostatism. Brist J Urol, 53: 613-616, 1981
Surgery : gold standard is TURP (etc)
Barkin J. Canadian Journal of Urology.2008;15(6), 4353-4358.AUA guidelines. J. Urol. 2003, 170, 530-547
Conclusion: which drug(s) to use?
Start -blocker (e.g. Harnal) for 1-2 weeks, add AREI if prostate enlarged (e.g. Avodart)
Start together (if finance alright)Change to alternative cheaper -blockerStart AREI only, if s/effects -blocker (BP low)Stop -blocker after 6 months, (77%, SMART1 study)Add anti-cholinergic anytime if bothersome OAB, (e.g.
Vescicare)PDE5 I eg Viagra, Cialis, Levitra, ZydenaTestosterone
Addon Vesicare to Harnal safe. J Urol 2009; 182: 2825-2830
Alpha blocker and Ureteric stones
• MET – medical expulsive therapy
• Tamsulosin & Ureter BJUI 2008 101 1061-2
Q & A Session 3
? Prostatitis, organisms & antibiotics
? Can a decrease of PSA with Avodart indicate no CaP ?
? Trial off catheter in AUR with no treatment?
? PIN, 1-3
? TURP complications, incl. ED
?
?
SELECT Trial
Selenium Vit E Placebo Combination
men, >55 yrs, n = 35,533
2001 - 4; No use
JAMA 2008; 301: 39-51
P C P T
Prostate Cancer Prevention Trial
Finasteride, n = 18882, 7 yrs.
Decrease Ca 24.4% to 18.4%
NEJM 2003; 349: 215-224
REDUCE
Reduction Dutasteride Cancer Events
n = 8231, 4 yrs
Reduce biopsy cancers from 11.8% to 9.1%
Andriole J Urol 2004; 172: 1314-7, AUA abstract 2009
Thank you