2022 - BPH over 80

Question 1

What challenges are involved in the medical management of BPH in elderly men?

Answer 1

Multiple comorbidities, polypharmacy, adverse effects, drug-drug interactions, limited data on medications for those over 80, and specific concerns regarding alpha blockers.

Question 2

What is FORTA classification, and how is it used in treating BPH in elderly men?

Answer 2

FORTA (Fit fOR The Aged) classification categorizes the safety and efficacy of medications for BPH in men over 65. It helps in selecting the right medication, considering factors like side effects and interactions.

Question 3

What are the key considerations in using alpha blockers in the management of BPH in elderly patients?

Answer 3

Alpha blockers like alfuzosin, doxazosin, tamsulosin, and silodosin are commonly used. Considerations include FORTA classification, side effects like orthostatic hypotension, intraoperative floppy iris syndrome (IFIS), interaction with cataract surgery, and sexual side effects.

Question 4

Figure. Treatment algorithm for the elderly male with BPH. OAB, overactive bladder. OSA, obstructive sleep apnea

Question 5

What factors must be considered for an individualized approach to BPH in men over 80?

Answer 5

Comorbidities, operative risk, polypharmacy, living environment, resources, and mental acuity.

Question 6

Why is understanding the living environment crucial in older patients with BPH?

Answer 6

To assess toileting abilities, fall risks, caregiver support, and choose the best treatment path.

Question 7

What diagnostic tools are important in understanding BPH issues in older men?

Answer 7

Voiding diaries, urodynamics, cystoscopy.

Question 8

What is the typical first-line therapy for BPH?

Answer 8

Medications, considering comorbidities, polypharmacy, and the FORTA classification.

Question 9

What should be considered when prescribing alpha blockers for BPH in the elderly?

Answer 9

Side effects like orthostatic hypotension, IFIS, and QTc prolongation. Only silodosin and tamsulosin are acceptable in the FORTA classification.

Question 10

What are the advantages and classification of 5ARIs in BPH treatment for the elderly?

Answer 10

Reduction of prostate volume, lack of adverse cognitive and cardiovascular effects, 3-4 months for symptom change, FORTA B classification.

Question 11

What is the role of PDE-5s in BPH treatment?

Answer 11

Treats both LUTS and ED, tadalafil FDA-approved for daily use, FORTA-C classification.

Question 12

What is the role and considerations of anticholinergics in BPH treatment for the elderly?

Answer 12

Reduces nerve impulses in bladder muscles, significant side effects in some types, fesoterodine preferred, FORTA classification varies.

Question 13

Describe the role and effects of beta-3 agonists like mirabegron in BPH treatment.

Answer 13

Causes detrusor relaxation, well-tolerated with low adverse effects, hypertension, and urinary tract infection as common effects.

Question 14

What are the combination therapies for BPH, and how effective are they?

Answer 14

Alpha Blocker and 5-ARI, Alpha Blocker and Anticholinergic; effective in reducing symptoms and progression.

Question 15

What are the roles of testosterone replacement and antiandrogens in BPH treatment?

Answer 15

Testosterone improves quality of life but risks prostate growth (mitigated with 5ARIs); antiandrogens for rapid reduction in prostate size.

Question 16

What are the special considerations for elderly patients undergoing BPH surgery?

Answer 16

Anesthetic risks, polypharmacy, anticoagulation, comorbidities, social factors, recovery components, frailty, and potential catheter use.

Question 17

What are MISTs, and what makes them attractive for frail men?

Answer 17

Low-risk office-based procedures like prostatic urethral lift, water vapor thermotherapy; may require anesthesia or sedation. Advantages and disadvantages listed in table 3.

Question 18

How is PAE used in BPH treatment, especially for frail older men?

Answer 18

Reasonable and safe treatment, beneficial for refractory/recurrent hematuria, concerns about contrast load and prolonged treatment times.

Question 19

What are the key considerations regarding anesthesia in elderly BPH surgery?

Answer 19

Hemodynamic and cognitive risks, limiting duration, regional approaches, risk of neurotoxicity, pressure ulcers, limited mobility, and traumatic fractures.

Question 20

What are the surgical approaches and potential modifications for elderly BPH patients?

Answer 20

: Avoiding monopolar TUR, laparoscopic, robotic, and open surgery; preferring laser procedures; modifying techniques like channel bipolar TUR; considering short-term hormonal therapy for untreated prostate cancer.

Question 21

What are the critical postoperative considerations for elderly men after BPH surgery?

Answer 21

Managing fluid intake, constipation, voiding symptoms, recurrent hematuria, potential catheter or suprapubic tube trials, antibiotics, consideration of 5ARIs or antiandrogens.

Question 22

What is the importance of assessing frailty in elderly patients undergoing BPH surgery?

Answer 22

Increased risk of complications, length of hospital stay, mortality; assessment tools like frailty phenotype and frailty index; lack of consensus on optimization; geriatric assessment advised.

Question 23

What are the concluding thoughts on treating BPH in older men?

Answer 23

Requires full assessment and thoughtful approach, considering voiding issues, treatment risks, patient frailty, living environment; tailored treatment options with multiple choices.

Question 24

What is the FORTA classification system for medical therapies used to treat BPH in men ≥65, and how are the medications classified?

Answer 24

FORTA A (Absolutely): None
FORTA B (Beneficial): Dutasteride, Finasteride (5ARI); Fesoterodine, Oxybutynin extended release, Solifenacin, Tolterodine, Trospium (Anticholinergic); Tadalafil (Phosphodiesterase inhibitor)
FORTA C (Careful/Caution): Darifenacin, Mirabegron (Anticholinergic); Alfuzosin, Doxazosin, Silodosin, Tamsulosin, Terazosin (Alpha blocker)
FORTA D (Do Not Recommend): Oxybutynin immediate release (Anticholinergic); Propiverine (Anticholinergic)

Question 25

What are the advantages and disadvantages of MIST procedures in treating BPH?

Answer 25

Advantages:
Office setting performance
Sedation options for those intolerant to local anesthesia
Fast procedures in experienced hands (e.g., prostatic urethral lift, water vapor thermotherapy)
No tissue removal (prevents sloughing or delayed complications)
No sexual side effects
Some therapies repeatable (e.g., water vapor thermotherapy, transurethral microwave therapy)

Question 26

What are the advantages and disadvantages of MIST procedures in treating BPH?

Answer 26

May not sufficiently improve symptoms
Prolonged treatment time for awake patients (e.g., transurethral microwave therapy)
Delayed symptom resolution due to lack of tissue removal
Utility in large prostates unproven for most methods
Potential post-procedure hematuria
Prostatic edema may require prolonged catheterization
May not be suitable or efficacious with middle lobes
Uncertain long-term durability in large prostates or those with a middle lobe

Question 27

What are the side effects and risks of Alpha Blockers in the treatment of BPH in elderly patients?

Answer 27

Orthostatic hypotension
Retrograde ejaculation
Rhinitis
Risk for IFIS
QTc prolongation
CHF exacerbation in selective patients

Question 28

What are the side effects and risks of Beta 3 Agonists in the treatment of BPH in elderly patients?

Answer 28

Hypertension
Cardiac arrhythmias
Dizziness
Headache
Constipation
Infections (e.g., cystitis, pharyngitis)

Question 29

What are the side effects and risks of PDE-5 Inhibitors in the treatment of BPH in elderly patients?

Answer 29

Headache
Dyspepsia
Nasopharyngitis
Back pain
Cardiovascular effects
Dizziness
Hypotension

Question 30

What are the side effects and risks of 5ARIs in the treatment of BPH in elderly patients?

Answer 30

Altered sexual function
Reduction of sexual libido
ED
Gynecomastia (no association with male breast cancer)

Question 31

What are the side effects and risks of Anticholinergics in the treatment of BPH in elderly patients?

Answer 31

Dry eyes and mouth
Blurred vision
Constipation
Fever
Flushing
Tachycardia
QT prolongation
Urinary retention
Psychosis/confusion