BPH can cause obstructive urinary symptoms eg h e s i s t a n c y , p o o r a n d
i n t e r m i t t e n t u r i n e f l o w , t e r m i n a l d r i b b l i n g a n d r e t e n t i o n .
Modern practice would require that the urine flow be documented with a
uroflowmetry. A normal uroflowmetry is >15 ml/sec. The post void residue
should also be <100 mls for most patients and any post void residue >300 mls
would be considered as having chronic retention with a risk of
hydronephrosis.
TWO types pf medicatons are used to treat BPH.
For patients whose prostate are proven to be enlarged (> 40 cc on rectal
exam or ultrasound per abdomen or transrectal TRUS), they will require a
medication to reduce the size of the prostate gland. This is done by
decreasing the dihydro-testosterone inside the prostate with A v o d a r t
(Dutasteride) or Proscar (Finasteride) daily. It takes 6 months to show any
clinical benefit. He will have to take this on a long term basis, possibly for
many years, until a better agent comes along. This agents cost about RM7
per day.
To improve his uroflow quickly (days) , one can use an alpha-blocker to relax
the adrenergic nerves to the prostatic urethra. The available ones include
Harnal (Tamsulosin), X a t r a l (Alfuzosin), Hytrin (Terazosin), Cardura
(Doxazosin). The side effects are those of postural hypotension and
ejaculatory disturbance. The cost range from RM1 to RM4 per day.
Other symptoms may not due to the prostate but from an overactive bladder,
OAB. These symptoms include f r e q u e n c y , n o c t u r i a , a n d u r g e n c y. In
such cases, an anti-cholinergic would be more useful e.g. Detrusitol
(Tolterodine or V e s i c a r e (Solifenacin).
If there is pain,one should exclude an UTI or stones.
If there is gross hematuria one need to exclude a bladder or renal tumour.
Bladder outlet obstruction and overactive bladder may be associated with
erectile dysfunction, ED. Many of these patients would also benefit from
PDE-5 inhibitor (phosphodiiesterases type 5) e.g. Sildenafil (Viagra),
Vardenafil (Levitra) or Tadalafil (Cialis). Sildenafil is now available as a
generic from Ranbaxy at just over RM10/- per table when the original Viagra
is about RM45/-. US FDA also recent approved d a i l y d o s e o f T a d a l a f i l
5 mg to be used for both erectile dysfunction and bladder outlet obstruction.
A further factor to improve patients with lower urinary tract symptoms is the
possibility of adding on testosterone hormonal replacement. A clue to such a
disorder (TDS, Testosterone Deficiency Syndrome) is that the patient has
other aspects of the metabolic syndrome e.g. obesity, hypertension, diabetesas well as loss of libido, erectile dysfunction, general tiredness. The biochemical diagnosis of TDS is finding a total testosterone of <11 nmol/ml. They can now be very effectively treated by intramuscular injection of
N e b i d o 1 gm every 3 months.
Thank you very much for your attention.
Dr Clarence Lei Chang Moh
Consultant Urologist
e-mail: clarencelei@gmail.com
13 January 2012
Ref:
Benign prostatic hyperplasia
(Diagram taken from http://en.wikipedia.org/wiki/Benign_prostatic_hyperplasia
Diagram illustrating normal prostate (left) and benign prostatic hyperplasia (right).
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