Prostatic hyperplasia, benign symptoms

Until the early 1990s, the described activities included diuretic, hemostatic, CNS-depre-ssant, antispasmodic, and antiallergenic. Since then the list has expanded to include antioxidant, analgesic, anti-inflammatory, antimicrobial, antihyperglycemic, antiulcer, antiplatelet aggregation, immunomodulatory and cardiovascular activities, as well as potential for treatment of benign prostatic hyperplasia (BPH) symptoms. 

Explain the pathophysiologic mechanisms underlying the symptoms and signs of benign prostatic hyperplasia. 

O The lower urinary tract symptoms and signs of benign prostatic hyperplasia are due to static, dynamic, or detrusor factors. The static factor refers to anatomic obstruction of the bladder neck caused by an enlarged prostate gland. The dynamic factor refers to excessive stimulation of a-adrenergic receptors in the smooth muscle of the prostate, urethra, and bladder neck. The detrusor factor refers to irritability of hypertrophied detrusor muscle as a result of long-standing bladder outlet obstruction. 

Surgical intervention should be reserved for patients with severe lower urinary tract symptoms of benign prostatic hyperplasia or those with complications of disease (such as recurrent urinary tract infections, renal failure, and bladder calculi). 

When monitoring efficacy of drug treatment for benign prostatic hyperplasia, subjective endpoints include relief of obstructive and irritative voiding symptoms. Objective endpoints include improvements of urinary flow rates, decreased post-void residual urinary volume, and decreased complications of disease. 

Enlarged prostate on digital rectal exam check for prostate nodules or induration, which would suggest prostate cancer instead of benign prostatic hyperplasia as the cause of the patient s voiding symptoms... 

Urinalysis to rule out infection as a cause of the patient s voiding symptoms also check urinalysis for microscopic hematuria, which typically accompanies benign prostatic hyperplasia. 

FIGURE 49-1. Algorithm for selection of treatment of BPH based on symptom severity. (From Lee M. Benign prostatic hyperplasia. In DiPiro JT, Talbert RL, Yee GC, et al, (eds.) Pharmacotherapy A Pathophysiologic Approach. 

Chappie CR. Pharmacological therapy of benign prostatic hyperplasia/ lower urinary tract symptoms an overview for the practicing clinician. BJU Int 2004 94 738-744. 

Djavan B, Chappie C, Milani S, Marberger M. State of the art on the efficacy and tolerability of alpha, adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Urology 2004 64 1081-1088. 

Milani S, Djavan B. Lower urinary tract symptoms suggestive of benign prostatic hyperplasia latest update on a, adrenoceptor antagonists. BJU Int 2005 95(Suppl 4) 29—36. 

Benign prostatic hyperplasia (BPH) is one of the most common problems of elderly men, affecting more than 40% of men over age 70. BPH results in the urinary symptoms of hesitancy and frequency. Since prostate cancer affects a similar age group and often has similar presenting symptoms, the presence of BPH often complicates the diagnosis of prostate cancer, although it does not appear to increase the risk of developing prostate cancer.2,5... 

Unfortunately, not all products that are used in clinical trials are available in the United States. In a randomized, double-blind, multicenter European study, 1069 men with moderate benign prostatic hyperplasia were randomized to receive saw palmetto (Permixon" )1 160 mg twice daily (90% free and 7% esterified fatty acids) or finasteride 5 mg once daily for 6 months [32]. As determined by patients and physicians, Permixon offered similar improvement in symptoms related to benign prostatic hyperplasia compared to finasteride. Since Permixon is not available in the United States, it should be recommended to patients to use a product that is similar to Permixon that contains a standardized extract of saw palmetto containing 85-95% sterols and fatty acids [18]. 

Benign prostatic hyperplasia (BPH) (Prascar on/yj.Treatment of symptomatic BPH in men with an enlarged prostate to improve symptoms, reduce acute urinary retention risk, and reduce the risk of the need for surgery including transurethral resection of the prostate (TURP) and prostatectomy. 

In the treatment of benign prostatic hyperplasia (BPH), the reduction in symptoms... 

Kuzmin, and R. R. Amdiy. Early urodynamic effects of the lipido-ste-rolic extract of Serenoa repens (Permixon ) in patients with lower urinary tract symptoms due to benign prostatic hyperplasia. Prostate Cancer Prostatic Dis 2000 3(3) 195-199. 

Geriatric Considerations - Summary Alpha-adrenergic blockers are modestly effective alone, and in combination with 5-alpha reductase inhibitors (e,g, finasteride) in the treatment of urinary obstructive symptoms related to benign prostatic hyperplasia. Alfuzosin is a "uroselective" alpha-blockerwhich appears to cause less orthostatic hypotension than nonselective alpha-blockers such as terazosin, prazosin, and doxazosin. 

Lowe FC. Roie of the newer alpha,-adrenergic-receptor antagonists in the treatment of benign prostatic hyperplasia-related lower urinary tract symptoms. Clin Ther... 

Terazosin is another reversible 04-selective antagonist that is effective in hypertension (see Chapter 11) it is also approved for use in men with urinary symptoms due to benign prostatic hyperplasia (BPH). Terazosin has high bioavailability but is extensively metabolized in the liver, with only a small fraction of unchanged drug excreted in the urine. The half-life of terazosin is 9-12 hours. 

Nickel JC, Sander S, Moon TD A meta-analysis of the vascular-related safety profile and efficacy of alpha-adrenergic blockers for symptoms related to benign prostatic hyperplasia. Int J Clin Pract 2008 62 1547. [PMID 18822025]... 

Roehrborn CG, Schwinn DA Alphai-adrenergic receptors and their inhibitors in lower urinary tract symptoms and benign prostatic hyperplasia. J Urol 2004 171 1029. [PMID 14767264]... 

In a Spanish systematic review of the world literature there were firm conclusions about the value of finasteride in reducing the symptoms of benign prostatic hyperplasia in doses that are well tolerated in all respects (36). 

Striking evidence of the association of finasteride with male breast cancer comes from the Medical Therapy of Prostatic Symptoms (MTOPS) study, a National Institutes of Health (NIH)-sponsored study of about 3047 men that compared finasteride, doxazosin, and the combination for the treatment of benign prostatic hyperplasia. The rate of breast cancer in this trial for men taking finasteride either alone or with doxazosin was four in 1554, or nearly 200 times that of the general population one man in the finasteride + doxazosin group and three in the finasteride-alone group developed male breast cancer (74). 

Inaba M, Otani Y, Nishimura K, Takaha N, Okuyama A, Koga M, Azuma J, Kawase I, Kasayama S. Combination therapy with rofecoxib and finasteride in the treatment of men with lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia. Metab Clin Exp 2005 54 55-9. 

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