Management of BPH and Prostatitis 3.1.2

Question 1

What are the treatment aims for BPH?

Answer 1

• Improving symptoms (by decreasing urinary outflow resistance)
• Reducing long-term complications

Question 2

What are some treatment considerations for BPH? What is the international prostate symptom score?

Answer 2

• Is BPH uncomplicated and patient not bothered by symptoms –> watchful waiting an option
• Aggravating factors such as constipation
• Prostate size
• Symptoms severity

> International prostate symptom score = monitor symptoms

• Mild 0-7
• Moderate 8-19
• Severe 20-35
• Quality of life due to urinary symptoms (1 is pleased, 6 is terrible)

Question 3

Why surgery for BPH? When is it preferred? What are the options?

Answer 3

• More effective than drug treatment
• Preferred when symptoms severe, drugs ineffecive, urinary retention
• Transsurethral resection of the prostate (TURP) - gold standard
• Open prostatectomy
• Urolift
• Minimially invasive techniques

> thermotherapy - TUMT ( transurethral microwave therapy), TUNA (trans-urethral needle ablation), laser treatment

Question 4

When is drug therapy considered for BPH?

Answer 4

Considered when

• symptoms troublesome
• patient’s preference
• surgery contraindicated/not indicated

Question 5

What are some factors influencing drug selection?

Answer 5

Prostate size = crucial

Symptom relief

Question 6

How long does selective alpha blockers take to work (APST)? What do they do?

Answer 6

• Symptom improvement in 48 hours (full effect in 4-6 weeks)
• Effective regardless of prostate size
• Improve urinary flow
• Indication: symptom relief in BPH and lasts for long term/time

Question 7

When is alfuzosin (more selective for prostate) CI? I?

Answer 7

• CI in hepatic impairment
• Metabolised by CYP3A4

Question 8

When to reduce dose for silodosin?

Answer 8

CrCL 30-60 mL/min?

Question 9

Has terazosin been discontinued?

Answer 9

Yas

Question 10

AE for alpha-1 blockers (APST)?

Answer 10

First dose hypotension (prazosin more common), dizziness, headache, urinary urgency, abnormal ejaculation

Question 11

Which are three alpha-1 blockers that has less BP effects and the better choice in BPH?

Answer 11

Alfuzosin, silodosin, tamsulosin = better choice in BPH

Question 12

Which alpha blocker have to take bd?

Answer 12

Prazosin (shorter DOA)

Question 13

Which alpha blocker has higest rate of ejucalatory abnormalities?

Answer 13

Silodosin

Question 14

Which alpha blocker causes floppy iris syndrome during cataract surgery?

Answer 14

all of them but tamsulosin especially

> high selectivity therefore have catarac surgery before starting alpha blocker

Question 15

What to monitor for alpha blockers?

Answer 15

efficacy, BP, symptoms of hypotension

Question 16

When to stop treatment if no benefits for alpha blockers?

Answer 16

after 4-6 weeks, should work beforte this period

Question 17

When are 5-alpha reductase inhibitors used? What benefits does it have in BPH?

Answer 17

Reserved for large prostates

> prostate greater than 30-40cm³

• can improve prostate size, rates of urinary retention, urinary flow, srugery

Question 18

How long does it take for symptom improvement and full effects for 5a-reductase inhibitors?

Answer 18

• 6 month for symptom improvement
• 12-18 months full effects

Question 19

Compare dutasteride and finasteride (5-alpha reductase inhibitors)

Answer 19

dutasteride = inhibit type 1 and type 2 of 5a isozymes = 90% reduction in DHT

finasteride = inibit type 1 = 70% reduction in DHT

Question 20

What are AE of 5-alpha reductase inhibitors

Answer 20

Decreased libido, impotence, ejaculatory disorders

> decreased testosterone levels

> less common = gynaecomastia and breast tenderness

Question 21

What is the half life of dutasteride and finasteride

Answer 21

dutasteride = 3-5 weeks

finasteride = 6 hours

Question 22

Why should pregnant women or those planning to get pregnant wear gloves when handing dutasteride and finasteride?

Answer 22

Casuses feminisation of male foetus

Question 23

Prostate specific antigen reduced by 50%, how long does it take for dutasteride and finasteride? What happens if drugs are stopped? What to do if PSA increases during treatment?

Answer 23

6 months of dutasteride

1 year for finasteride

• PSA returns to baseline after 6 months treatment cessation
• If PSA increases during treatment –> assess for prostate cancer

Question 24

Why use combination therapy of Alpha blocker and 5a RI? How long for the maximum effect of selective alpha blocker?

Answer 24

Prostate greater than 30-40cm³ = 5a reductase inhibitor

Fast relief of symptoms needed = alpha blocker

Selective alpha-blocker can be stopped after 6-12 months maximum effect reached at this time

Question 25

Any other options for BPH? Is any complementary medicines effective for BPH?

Answer 25

* Watchful waiting * Tadalafil * Anticholienrgic in continiuing bladder overactivity * CAMs Only CAMs that are likely safe and likely effective are * Beta sitosterol * Pygeum

Question 26

How is beta-sitosterol helpful for BPH?

Answer 26

Improves urinary symptoms, maximum urinary flow, post-void residual urine volume \> no effect on prostate size

Question 27

How is pygeum helpful for BPH?

Answer 27

Shown to decrease nocturia (19%) Increase peak urine flow (23%) Residual urine volume (24%)

Question 28

Is saw palmetto an option for BPH?

Answer 28

Likely safe but possibly ineffective \> widely used but data conflicting

Question 29

Non-pharmacological considerations for BPH?

Answer 29

* Avoid cold temperatures (urge to urinate), wetness * Relax when urinating, avoid letting bladder get full * Pelvic floor exercises * Stress reduction * Restrict fluid intake at bedtime * Reduce coffee, alcohol and spicy foods * No smoking * Avoid anticholinergic medications (eg OTC antihistamines, can promote urinary retention)

Question 30

Treatment aims for BPH?

Answer 30

* Symptom relief * Cure infection * Reduce complications

Question 31

What to use for mild to moderate infection (empirical) for acute BP

Answer 31

Oral trimethoprim or ciprofloxacin for 2-4 weeks (AMH) Oral trimethoprim or cefalexin for 2 weeks (eTG)

Question 32

What to use for severe infection for BP (short term empirical)? What to ensure for BP ?

Answer 32

* IV antibiotics, fluid replacement * Amoxicillin/ampicillin plus gentamicin (renal considerations) * Ceftriaxone or cefotaxime (when gentamicin C/I) Ensure: hydration, stool softener (constipation worsens pain), rest, analgesia (NSAID), paracetamol

Question 33

What to use for chronic bacterial prostatitis? \> penetration of AB is less in chronic so use strong ones

Answer 33

Trimethoprim, norlfoxacin or ciprofloxacin for 4-6 weeks (AMH), 4 weeks (eTG) doxycycline and option (if Ureaplsama or C.trachomatis)

Question 34

What to use for chronic non-bacterial prostatitis?

Answer 34

* Frequent relapses, difficult to manage * No proven treatment \> AB (as per CBG) if suspected undiagnosed bacterial infection \> Analgesia and address constipation \> Selective alpha-blockers for symptom relief \> Querrectin 500mg bd or pollen extract (cernilton)

Question 35

What is quercetin? What is its role in chronic NBP?

Answer 35

Flavonol, belonging to the class of flavonoids * occurs in red wine, onions, green tea, apple, berries, cababge, broccoli, cauliflower, turnips * also found in gingko biloba, St John's wort, american elder In chronic NBP: * reduces pain and improves QOL

Question 36

What are some considerations for prostatitis?

Answer 36

* Avoid nitrofurantoin --\> poor penetration for ABP * Rarely sexually transmitted or systemic pathogens are involved in acute prostatitis * Very rarely sexually transmitted pathogen in chronic bacterial prostatitis * Chronic non-bacterial prostatitis: reduce stress, physiotherapy, relaxation

Question 37

What to avoid during quinolone treatment?

Answer 37

Avoid quercetin --\> reduced efficacy