dr.

Dhirajaya Dharma Kadar, SpU

Urology Division, Department of Surgery

Adam Malik General Hospital
Faculty of Medicine, University of Sumatera Utara

Managing Prostate
Symptoms in
Andropause Males
Physiologic changes
Definitions: Primarily sexual and reproductive changes in aging male

Body
Erection Ejaculation Testosterone
Composition
Erection takes Decreased Serum Testost Decreased 
2-3 times force of erone Lean Body Ma
longer ejaculation   ss
decreases for /decreased
age over 50 strength
Prolonged Decreased
years
refractory awareness of
phase ejaculation
Testosterone L Upper and
evel central body
Partially lost  s drop 1% per fat increases
Erection year ages 40- with age
 difficult to 70 years
return to full

Bain J. Epidemiology, evaluation and diagnosis of andropause. Geriatrics & Aging 2003;6(10):9-14.
 Decrease of cognitive abilities
Rise of LH and FSH
Erectile dysfunction
Benign Prostatic Hyperplasia
Testosterone

ANDROPAUSE
Growth hormones
Lowered lean body mass and overall strength
Accumulation of subcutaneous fat
Increased LDL
Osteoporosis
TYPE 2 Reduced sex drive
DIABETES Poor general health
MELLITUS
Memory loss
Hair loss
The prevalence of BPH, BPE and LUTS increases with age1-3

100 Sixth decade of life

BPH*3 70%
80
Prevalence %
BPE§1 50%
60
LUTS1 50%
(moderate to severe)
40

20
LUTS+BPE
34%
0
31‒40 41‒50 51‒60 61‒70 71‒80 81‒90
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.
 BPH significantly impacts activities of daily living

Cross-sectional survey of 1610 men aged 40‒79 years in central Scotland

60
Percentage of men reporting that urinary symptoms interfered with BPH absent
activities of daily living at least some of the time during the past month
50 BPH present

40
34.7
32.4
29.9
30 27.1
Patients (%)

21.0
20 18.4
15.1
13.2 13.4 12.8
10.3
10 8.0
6.7 6.2

Adapted from Garraway WM et al. Br J Gen Pract 1993;43:318-21.

BPH is a progressive condition and will get worse if
suboptimally treated1-3
Over time, men with BPH may experience…

Clinical progression Long term

complications

• Worsening • Acute urinary

symptoms retention
• Worsening QoL • BPH-related
• Deterioration of surgery
peak urinary • Urinary stone
flow disease
• Increase in • Renal function
prostate volume deterioration

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.
Symptom review
to identify and classify LUTS 1
• Slow stream / Splitting or spraying
Voiding Symptoms • Intermittent stream
(obstructive) • Hesitancy
• Straining

• Frequency
Storage Symptoms • Nocturia
(irritative) • Urgency
• Urge Incontinence

• Feeling of incomplete emptying

Post Micturition • Post micturition dribble
Symptoms

1 -Abrams P et al. Neurourol Urodyn 2002;21:167-78.

 Treatment objectives for patients with LUTS/BPH

Alleviate symptoms

Alter disease progression

Prevent complication

McVary T et al. AUA Guidelines on Management of Benign Prostatic Hyperplasia (BPH). (2010; reviewed and validity confirmed in 2014. at http://www.auanet.org/guidelines/benign-
prostatic-hyperplasia-(2010-reviewed-and-validity-confirmed-2014) (Accessed: June 2017)
Treatment options for LUTS/BPH1

Conservative Medical Surgical

treatment treatment treatment
• Watchful waiting • Alpha-blockers (AB) • TURP
• Education • 5-alpha reductase • Open
• Lifestyle advice / inhibitors (5ARI) prostatectomy
modification • Phosphodiesterase-
5 inhibitors (PDE5-I)
• Antimuscarinics
• Beta-3 agonist
• Combination
therapy

1 - Gravas S, et al. Treatment of Non-neurogenic Male LUTS European Association of Urology Guidelines 2017; accessed on June.2017 through http ; //
uroweb.org/guidelines/treatment of non-neurogenic-male-luts#
Education and lifestyle advice
Education Types of toileting and bladder re-training
• Discuss the causes of LUTS, including normal • Advise men to double-void
prostate and bladder function • Advise urethral milking for men with post-
micturition dribble
• Discuss the natural history of BPH and LUTS,
including the expected future symptoms • Advise bladder retraining

Fluid management
• Advise a daily fluid intake of 1500–2000 mL
• Advise fluid restriction when symptoms are most inconvenient
• Advise evening fluid restriction for nocturia

Caffeine and alcohol Miscellaneous

• Avoid caffeine by substituting with alternatives • Avoid constipation in men with LUTS
• Avoid alcohol in the evening if nocturia is • Provide assistance if with impairment of
bothersome dexterity, mobility, or mental state
• Substitute large volume alcoholic drinks

Roehrborn CG et al. BJU Int 2015;116:450–459.

Terapi Medikamentosa: IAUI, 2015
LE GR
Alpha-1 blocker dapat diberikan pada kasus BPH dengan gejala sedang- 1a A
berat

LE GR
5-alpha reductase inhibitor dapat diberikan pada kasus BPH gejala sedang- 1b A
berat dan prostat yang membesar
5-alpha reductase inhibitor dapat mencegah progresivitas yang 1b A
berhubungan dengan retensi urin akut dan tindakan pembedahan

LE GR
Antagonis reseptor muskarinik dapat digunakan pada kasus BPH dengan 1b B
keluhan storage yang menonjol
Hati-hati pada kasus BPH dengan gejala voiding 4 c

LE GR
PDE-5 Inhibitor dapat mengurangi gejala LUTS sedang sampai berat pada 1a A
pria dengan atau tanpa disfungsi ereksi
Terapi Medikamentosa Kombinasi
LE GR
Pengobatan kombinasi alpha-1 blocker dengan 5-alpha reductase 1b A
inhibitor dapat ditawarkan kepada pasien BPH dengan gejala LUTS
sedang sampai berat

LE GR
Terapi kombinasi antara alpha-1 blocker dengan antagonis 1b B
reseptor muskarinik dapat diberikan pada kasus LUTS terutama
pada kasus dengan keluhan storage yang tidak membaik dengan
pemberian monoterapi
Terapi kombinasi ini perlu dipantau lebih ketat apabila diberikan 2b B
kepada kasus BPH dengan gangguan voiding

Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak IAUI. 2015

If most prostate symptoms is
acquired in andropause men,
then what are the problems?

• The problems emerged when a

Testosterone replacement therapy has
to be given in male with history of
prostate cancer.
• The target of therapy in prostate
cancer is to achieve PSA nadir through
serum castration level of testosterone.
• Then how about the quality of life?
 When to refer to the urologist1-3?

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) • Uncertain diagnosis
• Suspicion of neurologic cause of • Unsuccessful initial
symptoms medical management
• Findings or suspicion of urinary
retention
• 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.
Conclusions
• Achieve “Optimal Diagnosis”
• BPH with mild symptoms  lifestyle modification, alpha-blocker
• BPH with moderate to severe symptoms  combination therapy
• Suspicion of Cancer (Nodule in DRE or PSA> 4)  refer to Urologist
• Testosterone replacement therapy should only be given with caution
in men with previous history of prostate cancer  refer to urologist
THANK YOU