Evaluation and Treatment of Lower Urinary Tract Symptoms in Men: Flow with me Through the Void

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1 Evaluation and Treatment of Lower Urinary Tract Symptoms in Men: Flow with me Through the Void The Lower Urinary Tract System in Men Janine Boivin, PA-C Normal Urination Overview of The Prostate Normal Urination Bladder Filled Sphincter Relaxation Bladder Contraction Urine Flow Walnut sized gland at base of the male bladder Surrounds the urethra Produces fluid that transports sperm during ejaculation Normal vs. Enlarged Prostate Prostate Conditions As the prostate enlarges, pressure can be put on the urethra causing urinary problems (LUTS) 1 Prostate size does not correlate with degree of obstruction or severity of symptoms. BPH (enlarged prostate) Prostate Cancer Prostatitis Each condition affects the prostate differently 1

2 What is BPH? Who Can Get BPH? Benign Prostatic Hyperplasia (BPH) Non-cancerous enlargement of the prostate gland BPH is not an indication nor a predictor of cancer The opposite is also true your PSA level is not an indicator of BPH A histologic diagnosis Proliferation of smooth muscle and epithelial cells within the prostate Often not life-threatening, but it can impact quality of life significantly BPH affects 50% of men over Affects 40-50% of men ages Affects 80%+ men over age Obesity, higher body mass index (BMI) and lack of exercise may increase the risk of BPH 3 BPH symptoms are treatable! Lower Urinary Tract Symptoms LUTS/BPH vs. BPH and LUTS Lower Urinary Tract Symptoms (LUTS) was initially thought to be related to prostate growth, urethral compression and obstruction, and irritable bladder Described as LUTS secondary to/or suggestive of BPH; often referred to as LUTS/BPH However, LUTS has a complex etiology with multiple factors involved Not all men with BPH have LUTS, and not all patients with LUTS have BPH Voiding and storage LUTS are common to both men and women, suggesting that LUTS may be unrelated to the prostate Andersson et al. Neurourol Urodyn 2011;30(3): LUTS: Lower Urinary Tract Symptoms LUTS Irritative (Bladder - OAB) Frequency Urgency Nocturia Urge Incontinence Obstructive (Prostate BPH) Hesitancy Weak Stream Prolonged Urination Intermittency Straining Incomplete Emptying Urinary Retention Overflow Incontinence Secondary Effects of Bladder Outflow Obstruction due to BPH BPH Evaluation Medical History Physical Exam (DRE) PSA AUA Symptom Score Severity of symptoms * Bother In general, the size of the prostate does not correlate to severity of symptoms 2

3 Additional Testing Post void residual (PVR) Bladder scan or In & Out Catheterization Cystoscopy Transrectal Ultrasound (TRUS) Uroflow Urodynamic studies Treatment Options BPH Treatment Options Overview Treatment Option - Watchful Waiting Advantages No surgery No drugs No side effects Disadvantages No improvement in symptoms Risk that symptoms will worsen Observation Treatment Option - Medication Advantages No surgery Potential for symptom relief Disadvantages Ongoing medication therapy Potential side effects Lowered sexual drive, erection problems, congestion and dizziness Effectiveness may diminish High out-of-pocket cost Many men don t like taking medications 3

4 AUA Guidelines for Medical Treatment of LUTS/BPH 1 -Adrenergic antagonists ( -blockers) For patients with bothersome moderate-to-severe symptoms 5 -Reductase inhibitors (5ARIs) For patients with symptoms of BPH and demonstrable prostate enlargement Combination therapy ( -blockers + 5ARIs) For patients with symptoms of BPH and demonstrable prostate enlargement Antimuscarinics As an alternative in patients without elevated postvoid residual urine when LUTS are predominantly irritative Are not approved by the FDA for treatment of BPH 2 Alpha Blockers Causes relaxation of smooth muscle in the bladder and prostate, resulting in symptomatic improvement. 1. McVary et al. J Urol 2011;185(5): Alpha-Adrenergic Blockers 5 -Reductase Inhibitors FDA-approved drugs: silodosin, alfuzosin, tamsulosin, doxazosin, a and terazosin a The clinical effectiveness of -blockers in patients with bothersome moderate-to-severe LUTS is similar Common adverse events are dizziness and ejaculation dysfunction Recommended for men with enlarged prostates to prevent progression of LUTS/BPH and to reduce the risk of urinary retention and future surgery Slow onset of symptom improvement (several months) Recommended for long-term treatment 5ARIs prevent the conversion of testosterone to DHT Finasteride reduces the levels of DHT in prostate tissues by about 80%, and dutasteride by about 94%, compared to placebo Approved medications: finasteride and dutasteride Adverse events: disturbances of sexual function (eg, decreased libido, ejaculatory dysfunction, and ED) a Require dose titration and blood pressure monitoring McVary et al. J Urol 2011;185(5): McVary et al. J Urol 2011;185(5): Combination Therapy ( -Blockers + 5ARIs) 1,2 Recommended for men with moderate to severe LUTS/BPH with an enlarged prostate Combination reduces disease progression and worsening of symptoms Adverse events were more frequent compared to monotherapy Surgical Treatments Open Prostatectomy Transurethral resection of the prostate (TURP) Microwave Therapy (TUMT) Laser surgery (PVP) 1. McVary et al. J Urol 2011;185(5):

5 LUTS: Lower Urinary Tract Symptoms LUTS Irritative (Bladder - OAB) Frequency Urgency Nocturia Urge Incontinence Obstructive (Prostate BPH) Hesitancy Weak Stream Prolonged Urination Intermittency Straining Incomplete Emptying Urinary Retention Overflow Incontinence Overactive Bladder Symptoms/LUTS Frequency one or more symptoms > 8 micturitions / 24 hours > 2 times / night (Nocturia) Urgency Strong desire to void at low bladder volumes Urge Incontinence Strong desire to void + involuntary urine loss Due to involuntary bladder contraction during filling Sources: Abrams P, Wein AJ The Overactive Bladder: A widespread and treatable condition. Erik Sparre Medical AB, 1998, Stockholm, Sweden, P. 44: Nishizawa O. Urology 1997:50 (Suppl 6A): 23 Overactive Bladder Causes BPH Bladder irritation (UTI, Dietary Irritants) Neurogenic (TIA, CVA, SCI) Age Idiopathic Treatment Options LUTs/OAB Sources: Roberts RO. JAGS, 1998:46: ; Johnson TM..JAGS, 2000:48: Treatment of Urge Incontinence and Overactive Bladder Anticholinergics: Mechanism of Action Behavioral Pharmacologic Surgery Decrease oral fluids Eliminate bladder irritants (caffeine, acidic fluids) Timed voiding Bladder training Anticholinergics: oxybutynin, tolterodine, solifenacin, tropsium, darifenacin, fesoterodine Beta agonist: mirabagron Tricycle antidepressant: Imipramine Botox injections Sacral nerve stimulator implant Augmentation cystoplasty Inhibits bladder spasms Increases bladder capacity Diminishes frequency of involuntary bladder contractions Delays initial urge to void 5

6 LUTs and BPH Symptoms of the lower urinary tract system in men are often related to the prostate and the bladder, so it is important to target both areas in evaluation and treatment. 6