Chapter 091. Benign and Malignant Diseases of the Prostate (Part 11)

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Benign Disease Symptoms Benign proliferative disease may produce hesitancy, intermittent voiding, a diminished stream, incomplete emptying, and postvoid leakage. The severity of these symptoms can be quantitated with the self-administered American Urological Association Symptom Index (Table 91-2), although the degree of symptoms does not always relate to gland size. Resistance to urine flow reduces bladder compliance, leading to nocturia, urgency, and, ultimately, urinary retention. An episode of urinary retention may be precipitated by infection, tranquilizing drugs, antihistamines, and alcohol. Prostatitis often produces pain or induration. Typically, the symptoms remain stable over time and obstruction does not occur. ...

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Chapter 091. Benign and Malignant Diseases of the Prostate (Part 11) Benign Disease Symptoms Benign proliferative disease may produce hesitancy, intermittent voiding, a diminished stream, incomplete emptying, and postvoid leakage. The severity of these symptoms can be quantitated with the self-administered American Urological Association Symptom Index (Table 91-2), although the degree of symptoms does not always relate to gland size. Resistance to urine flow reduces bladder compliance, leading to nocturia, urgency, and, ultimately, urinary retention. An episode of urinary retention may be precipitated by infection, tranquilizing drugs, antihistamines, and alcohol. Prostatitis often produces pain or
induration. Typically, the symptoms remain stable over time and obstruction does not occur. Table 91-2 AUA Symptom Index AUA Symptom Score (Circle 1 Number on Each Line) Questi Not Le Le Abo Mo Alm ons to Be at All ss than 1 ss than ut Half re than ost Always Answered Time in Half the the Time Half the 5 Time time Over 0+ 1 2 3 4 5 the past month, how often you have had a sensation of not emptying your bladder completely
after you finished urinating? Over 0 1 2 3 4 5 the past month, how often have you had to urinate again less than 2 h after you finished urinating? Over 0 1 2 3 4 5 the past month, how often have you found you stopped and
started again several times when you urinated? Over 0 1 2 3 4 5 the past month, how often have you found it difficult to postpone urination? Over 0 1 2 3 4 5 the past month, how often have you had a weak urinary stream?
Over 0 1 2 3 4 5 the past month, how often have you had to push or strain to begin urination? Over (No (1 (2 (3 (4 (5 the past ne) time) times) times) times) times) month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in
the morning? Sum of 7 circled numbers (AUA Symptom Score): ____ Note: AUA, American Urological Association. Source: Barry MJ et al: J Urol 148:1549, 1992. Used with permission. Diagnostic Procedures and Treatment Asymptomatic patients do not require treatment regardless of the size of the gland, while those with an inability to urinate, gross hematuria, recurrent infection, or bladder stones may require surgery. In patients with symptoms, uroflowmetry can identify those with normal flow rates who are unlikely to benefit from surgery and those with high postvoid residuals who may need other interventions. Pressure-flow studies detect primary bladder dysfunction. Cystoscopy is recommended if hematuria is documented and to assess the urinary outflow tract
before surgery. Imaging of the upper tracts is advised for patients with hematuria, a history of calculi, or prior urinary tract problems. Medical therapies for BPH include 5α-reductase inhibitors and α-adrenergic blockers. Finasteride (10 mg/d PO) and other 5α-reductase inhibitors that block the conversion of testosterone to dihydrotestosterone decrease prostate size, increase urine flow rates, and improve symptoms. They also lower baseline PSA levels by 50%, an important consideration when using PSA to guide biopsy recommendations. α-Adrenergic blockers such as terazosin (1–10 mg PO at bedtime) act by relaxing the smooth muscle of the bladder neck and increasing peak urinary flow rates. No data show that these agents influence the progression of the disease. Surgical approaches include TURP, transurethral incision, or removal of the gland via a retropubic, suprapubic, or perineal approach. Also utilized are TULIP (transurethral ultrasound-guided laser-induced prostatectomy), stents, and hyperthermia. Further Readings Loblaw DA et al: Initial hormonal management of androgen-sensitive metastatic, recurrent or progressive prostate cancer: 2006 update of an American Society of Clinical Oncology practice guideline. J Clin Oncol 25:1596, 2007
[PMID: 17404365] Loeb S, Catalona WJ: Prostate-specific antigen in clinical practice. Cancer Letters 249:30, 2007 [PMID: 17258389] Nelson WG et al: Prostate cancer. N Engl J Med 349:366, 2003 [PMID: 12878745] Scher HI, Heller G: Clinical states in prostate cancer: Toward a dynamic model of disease progression. Urology 55:323, 2000 [PMID: 10699601] Tannock IM et al: Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer. N Engl J Med 351:1502, 2004 [PMID: 15470213] Thompson IM et al: The influence of finasteride on the development of prostate cancer. N Engl J Med 349:215, 2003 [PMID: 12824459] Thorpe A, Neal D: Benign prostatic hyperplasia. Lancet 366:1359, 2003 Yao SL, DiPaola RS: Evidence-based approach to prostate cancer follow-
up. Semin Oncol 30:390, 2003 [PMID: 12870141]