Professional Documents
Culture Documents
paksisatyagraha@gmail.com
@paksi_PAS
uropas.fk@ub.ac.id
Definitions of terms used in the context of BPH1-3
1. Abrams P et al. J Urol 2013;189: S93-S101; 2. McVary T et al. AUA Guideline. Revised 2010. Available at: http://www.auanet.org/common/pdf/education/clinical-
guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016); 3. Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology
Guidelines 2016; accessed on 28-04-16 through http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#3
For Healthcare Professional Use only
What do we call BPH?
Bladder
Central and
Prostate peripheral zones
Transition zone
Urethra
Thailand
13,000,000 2,000,000
2001 2006 2011 2016 2021 2026 2001 2006 2011 2016 2021 2026
years years
Data from database: Health Nutrition and Population Statistics: Population estimates and projections. Last accessed April 2016;
http://databank.worldbank.org/data/reports.aspx?source=Health%20Nutrition%20and%20Population%20Statistics:%20Population%20estimates%20and
%20projections
The prevalence of BPH, BPE and LUTS
increases with age1-3
100 Sixth decade of life
BPH*3 70%
80
Prevalence %
60
BPE§1 50%
LUTS1 50%
40 (moderate to severe)
20 LUTS+BPE
34%
0
31‒40 41‒50 51‒60 61‒70 71‒80 81‒90
Data from different studies
Age (years)
*Prevalence of BPH in 1075 human prostate collected at autopsy; § Determined by digital rectal examination with a result of enlarged or not enlarged (n=448 )
Adapted from 1. Naslund MJ et al. Int J Clin Pract 2007;61:1437-45; 2. Verhamme KM et al. Eur Urol 2002;42:323-8; 3. Berry SJ et al. J Urol 1984;132:474-79.
STATISTIC IN SAIFUL ANWAR GENERAL HOSPITAL
66% 48%
of men spontaneously of men reporting routinely
presenting to GP clinics to GP clinics have an
with LUTS have BPH enlarged prostate (DRE)
1. Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology Guidelines 2016; accessed on 28-04-16 through
http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#3 2. Parsons JK. Curr Bladder Dysfunct Rep 2010;5:212–8; 3. Carballido J et al. Int J
Clin Pract 2011;65:989-96; 4. Naslund MJ et al. Int J Clin Pract 2007;61:1437-45.
BPH is a progressive condition and will get
worse if suboptimally treated1-3
1. Emberton M et al. Urology 2003;61:267-73; 2. Emberton M et al. Int J Clin Pract 2008:62:1076-86; 3. Fitzpatrick JM. BJU Int 2006;97(Suppl. 2):3-6.
For Healthcare Professional Use only
BPH significantly impacts daily living activities
Cross-sectional survey of 1610 men aged 40‒79 years in central Scotland
40
Patients (%)
34.7
32.4
29.9
30 27.1
21.0
20 18.4
15.1
13.2 13.4 12.8
10.3
10 8.0 6.7 6.2
0
Limits fluids Limits going to Limits fluids Not getting Cannot drive Limits going to Limits playing
before places without before travel enough sleep for two hours cinema, outdoor sports
bedtime toilets at night theatre,
church etc.
Patients (N=4979) presenting with LUTS in six European countries were evaluated for co-morbidities
Often seen as
Develop coping strategies
part of aging1,2,3
including self-medication
and structuring of daily
activities1
Men´s views
of LUTS
Embarrassment is a key reason men do not discuss LUTS with their physician 2,3
1. Gannon K et al. J Health Psychol 2004;9:411-420; 2. Carballido J et al. Int J Clin Pract 2009;63:1192-1197;
3. Kuritzky L. Rev Urol 2003;5(suppl 5):S42-S48.
Accurate assessment of male LUTS is crucial
because…
1. Gratzke C et al. Eur Urol 2015;67:1099-109; 2. McVary T et al. AUA Guideline. Revised 2010. Available at:
http://www.auanet.org/common/pdf/education/clinical-guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016)
Initial assessment
1,2,3
on presentation with LUTS
Clinical assessment tests
Physical
Relevant medical Symptom score
Urinalysis examination
history questionnaires
including DRE
PSA: Prostate specific antigen; EAU: European Association of Urology; AUA: American Urological Association
1. Gratzke C et al. Eur Urol 2015;67:1099-1109; 2. McVary T et al. AUA Guideline. Revised 2010. Available at: http://www.auanet.org/common/pdf/education/clinical-
guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016); 3. Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology
Guidelines 2016; accessed on 28-04-16 through http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#
Initial assessment
1,2,3
on presentation with LUTS
Clinical assessment tests
Physical
Relevant medical Symptom score
Urinalysis examination
history questionnaires
including DRE
1. Gratzke C et al. Eur Urol 2015;67:1099-1109; 2. McVary T et al. AUA Guideline. Revised 2010. Available at: http://www.auanet.org/common/pdf/education/clinical-
guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016); 3. Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology
Guidelines 2016; accessed on 28-04-16 through http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#
Initial assessment
1,2,3
on presentation with LUTS
Clinical assessment tests
Physical
Relevant medical Symptom score
Urinalysis examination
history questionnaires
including DRE
1. Gratzke C et al. Eur Urol 2015;67:1099-1109; 2. McVary T et al. AUA Guideline. Revised 2010. Available at: http://www.auanet.org/common/pdf/education/clinical-
guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016); 3. Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology
Guidelines 2016; accessed on 28-04-16 through http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#
Relevant medical history needed to assess the potential cause of LUTS
Physical
Relevant medical Symptom score
Urinalysis examination
history questionnaires
including DRE
1. Gratzke C et al. Eur Urol 2015;67:1099-1109; 2. McVary T et al. AUA Guideline. Revised 2010. Available at: http://www.auanet.org/common/pdf/education/clinical-
guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016); 3. Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology
Guidelines 2016; accessed on 28-04-16 through http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#
Urinalysis is used to determine other conditions1,2
A recommended primary evaluation in the presence of LUTS
Physical
Relevant medical Symptom score
Urinalysis examination
history questionnaires
including DRE
1. Gratzke C et al. Eur Urol 2015;67:1099-1109; 2. McVary T et al. AUA Guideline. Revised 2010. Available at: http://www.auanet.org/common/pdf/education/clinical-
guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016); 3. Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology
Guidelines 2016; accessed on 28-04-16 through http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#
Classification of LUTS
IPSS questionnaire may not be practical in the busy primary care setting3,4
IPSS cannot be used as a diagnostic tool since other conditions can cause similar symptoms 3
1. Madersbacher S et al. Eur Urol 2004;46:547-554; 2. McVary T et al. AUA Guideline. Appendix 1A. Revised 2010. Available at:
http://www.auanet.org/common/pdf/education/clinical-guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016); 3. Rosenberg MT et al.
Int J Clin Pract 2007;61:1535-46; 4. Carballido J et al. Int J Clin Pract 2011;65:989-96.
International prostate symptom score IPSS
Assessment of severity and bother of LUTS in men (2/2)
The last item of the IPSS questionnaire is a separate assessment of quality of life
based on a score range from 0-61,2
1. Madersbacher S et al. Eur Urol 2004;46:547-554; 2. McVary T et al. AUA Guideline. Appendix 1A. Revised 2010. Available at:
http://www.auanet.org/common/pdf/education/clinical-guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016)
Initial assessment
1,2,3
on presentation with LUTS
Clinical assessment tests
Physical
Relevant medical Symptom score
Urinalysis examination
history questionnaires
including DRE
1. Gratzke C et al. Eur Urol 2015;67:1099-1109; 2. McVary T et al. AUA Guideline. Revised 2010. Available at: http://www.auanet.org/common/pdf/education/clinical-
guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016); 3. Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology
Guidelines 2016; accessed on 28-04-16 through http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#
Performing a digital rectal exam (DRE)
A recommended assessment in presence of LUTS to evaluate:
• Prostate size/volume
• Prostate shape
• Prostate consistency and
abnormalities suggestive of
prostate cancer
• Anal sphincter tone
Gratzke C et al. Eur Urol 2015;67:1099-1109. McVary T et al. AUA Guideline. Revised 2010. Available at:
http://www.auanet.org/common/pdf/education/clinical-guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016).
Furlan A et al. Int Braz J Urol 2008;34:572-76.
Initial assessment
1,2,3
on presentation with LUTS
Clinical assessment tests
Physical
Relevant medical Symptom score
Urinalysis examination
history questionnaires
including DRE
1. Gratzke C et al. Eur Urol 2015;67:1099-1109; 2. McVary T et al. AUA Guideline. Revised 2010. Available at: http://www.auanet.org/common/pdf/education/clinical-
guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016); 3. Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology
Guidelines 2016; accessed on 28-04-16 through http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#
Prostate serum antigen (PSA) testing1,2
• PSA is used in the diagnosis of prostate
cancer
• PSA levels vary with age
• Along with prostate size, serum PSA
provides prognostic information about:
– Prostate growth
– Symptoms and bother deterioration
– Flow rate worsening
– Risk for AUR and surgery
1. Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology Guidelines 2016; accessed on 28-04-16 through
http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#; 2. McVary T et al. AUA Guideline. Revised 2010. Available at: http://www.auanet.org/common/pdf/
education/clinical-guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016); Image reproduced with permission from iStock
PSA and total prostate volume have a
strong age-dependent relationship
The close correlation between prostate volume and PSA enables
PSA to be used as a surrogate to estimate prostate volume
70 75
70
65
65
60
60
55 55
50
50
45
45 40
40 Age
(years)
35
30
1 2 3 4 5 6 7 8
Serum PSA (ng/mL)
Reprinted from Urology, vol 53, Roehrborn CG, et al, Serum prostate-specific antigen as a predictor of prostate volume in men with benign prostatic hyperplasia, pp 581-9, Copyright 1999 with permission from Elsevier.
.
Initial assessment
1,2,3
on presentation with LUTS
Clinical assessment tests
Physical
Relevant medical Symptom score
Urinalysis examination
history questionnaires
including DRE
1. Gratzke C et al. Eur Urol 2015;67:1099-1109; 2. McVary T et al. AUA Guideline. Revised 2010. Available at: http://www.auanet.org/common/pdf/education/clinical-
guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016); 3. Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology
Guidelines 2016; accessed on 28-04-16 through http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#
Frequency volume chart (FVC) and bladder diary
Assessment of LUTS with a prominent storage component or nocturia
Voiding diary
Time Intake Urge Voided Leak Activity
9.10 x x
3 days
10.15 water 1 cup
10.30 x standing
Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology Guidelines 2016; accessed on 28-04-16 through
http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#
GPs can use assessment data to build BPH
patient risk profile1
Risk factors for disease progression include:
1. Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology Guidelines 2016; accessed on 28-04-16 through
http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#; 2. Emberton M et al. Int J Clin Pract 2008; 62:1076-86; 3. Tanguay S et al. Can Urol
Assoc J 2009;3(Suppl2):S92-100.
When to refer to the urologist?
Based on patient assessment1-3
Complicated LUTS
• History of recurrent urinary tract Suspicion of prostate cancer
infections or other infection
• Microscopic or gross hematuria • Elevated PSA Other
• Prior genitourinary surgery • Abnormal prostate
exam (nodules) • Elevated prostate
• Suspicion of neurologic cause symptoms
of symptoms • Uncertain diagnosis
• Findings or suspicion of urinary • Unsuccessful initial
retention medical management
• Meatal stenosis
• History of genitourinary trauma
• Pelvic pain
1. Rosenberg MT et al. Int J Clin Pract 2007;61:1535-46; 2. Kuritzky L. Rev Urol 2003;5(Suppl 5):S42-8; 3. Kapoor A. Can J Urol 2012;19(Suppl 1):10-7.
Objectives of clinical assessment of
men with LUTS1,2,3
Establish
a differential diagnosis
Identify
men at risk of
progression
Define
Assess the clinical profile
patients’ values
Conservative
and preferences
treatment
Provide
Minimise the best evidence-based care Medical treatment
disease progression
and complications
Surgical treatment
1. Gratzke C et al. Eur Urol 2015;67:1099-109; 2. McVary T et al. AUA Guideline. Revised 2010. Available at: http://www.auanet.org/common/pdf/education/clinical-
guidance/Benign-Prostatic-Hyperplasia.pdf (Accessed: May 2016); 3. Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology
Guidelines 2016; accessed on 28-04-16 through http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#;
Treatment options of LUTS
• Alpha-blockers (AB)
Medical treatment • 5-alpha reductase inhibitors (5-ARI)
• Phosphodiesterase-5 (PDE-5) inhibitors
• Muscarinic receptor antagonists
• Beta-3 agonist
• Combination therapy
- AB + 5-ARI
- AB + muscarinic receptor antagonist
PDE-5i
• Indicated for BPH with ED
Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology Guidelines 2016; accessed on 28-04-16 through
http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#.
SMOOTH
BPH MUSCLE
TONUS:
Dynamic
PROSTATIC
Static Dynamic MASS:
component component Static
Voiding
problems
Alpha
adrenergik
receptor
Bladder
Storage distribution in
aging problems the lower
Neuropathic urinary tract
Bladder
Enlarged
prostate Urethra Relaxed
gland smooth
Open
lumen muscle
• Provide rapid (hours to days) relief of symptoms and improved urinary flow
Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology Guidelines 2016; accessed on 28-04-16 through
http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#.
5-alpha reductase inhibitors (5-ARI)
• Molecules: dutasteride and finasteride
• Inhibit the conversion of testosterone to dihydrotestosterone which is the
androgen predominantly responsible for prostate growth
Bladder
Enlarged
prostate gland Urethra
Type1
5AR
–Testosterone
Testosterone Dihydrotestosterone
Type2
5AR Shrunken
Open
prostate gland
lumen
– Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology Guidelines 2016; accessed on 28-04-16 through
http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#.
5-alpha reductase inhibitors (5-ARI)
Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology Guidelines 2016; accessed on 28-04-16 through
http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#.
5-alpha reductase inhibitors (5-ARI) tolerability
Gravas S et al. Treatment of Non-neurogenic Male LUTS European Association of Urology Guidelines 2016; accessed on 28-04-16 through
http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#.
Combination therapy
Alpha-blocker + 5-ARI
Alpha-
5-ARI
blocker
Improve symptoms/flow
Onset of symptom relief in 1–2 weeks
Prevent symptomatic progression (short term)
Sustained symptomatic benefit
Reduce PV
Maintain reductions in PV
Reduce long-term risk of AUR and surgery
1. Madersbacher S et al. Eur Urol 2004;46:547-54; 2. Madersbacher S et al. Eur Urol 2007;51:1522-33; 3. Roehrborn C, Heaton J. Eur Urol
2006;5(Suppl);716-21.
Alpha-blocker + 5-ARI combination therapy
Primary endpoint
AUA-SS/IPSS and Qmax
Dutasteride + Tamsulosin The only [5ARI + α1-blocker] combinations assessed for efficacy and safety in
Finasteride + Doxazosin long-term RCTs
1. Füllhase C, et al. Eur Urol 2013 Aug;64(2):228-43; 2. Roehrborn CG, et al. Eur Urol 2010 Jan;57(1):123-31; 3. Roehrborn CG, et al. J Urol 2008 Feb;179(2):616-21. 4. Roehrborn CG et al. BJU Int 2015;116:450–459
• 5ARI (finasteride) • 5ARIs (fin and dut) • 5ARI (fin and dut) 5ARI and 5ARI+AB
• 5ARI+AB was not • 5ARI+AB (MTOPS) • 5ARI+AB (MTOPS with specific thresholds
recommended and CombAT ) for PV and PSA
Year
1. IMS MIDAS database 2001-2014; 2 Eurostat accessed on 20/01/16 through http://ec.europa.eu/eurostat/data/database; 3. Cornu JN, et al. Eur Urol 2010; 4. De la Rosette et al. EAU Guidelines on Benign Prostatic
Hyperplasia (2001); 5 Madersbacher S et al. Eur Urol 2004;46:547–554; 6. Oelke M et al Management of Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO) (2012)
1. Rosenberg MT et al. Int J Clin Pract 2007;61:1535-46; 2. Carballido J et al. Int J Clin Pract 2011;65:989-96; 3. Gravas S et al. Treatment of
Non-neurogenic Male LUTS European Association of Urology Guidelines 2016; accessed on 28-04-16 through
http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#.
Combination Therapy
Selected
Combination therapy of Cases: higher prostate volume
BPH maybe superior in
IPSS outcome,
especially in chronic higher PSA
use. But it also poses concentration
more risks.
advanced age
higher PVR
Combination therapy of
BPH can have benefits
on selected cases. lower urinary flow