Benign Prostatic Hyperplasia (BPH)

William R. Mikesell, PharmD

PGY1 Pharmacy Resident
Lutheran Hospital
About Me:
Objectives:
• Recognize diagnosis and evaluation of BPH
• Describe the impact of BPH and disease
progression in patients
• Identify non-pharmacologic treatments for
BPH
• Identify pharmacological drugs for BPH
including basic characteristics
• Evaluate proper therapy for patient scenarios
including monitoring, therapy adjustments, and
counseling
It’s just a part of aging…
• BPH is one of the most common diseases in
aging
• Affects the QOL in approximately ⅓ of men
older than 50
• As many as 14 million men in the US and 30
million men worldwide have symptoms related
to BPH
• Retention can lead to renal failure, CKD,
recurrent UTIs, gross hematuria, and bladder
calculi, diverticula
• Tissue growth exceeds blood supply which
leads to persistent hematuria
Diagnosis:
Evaluation:
History:
• Other known medical conditions
• Complete list of all symptoms
• Medication History (Check for drugs that
worsen BPH)
• Centrally acting anticholinergics (Benztropine)
• Antihistamines (diphenhydramine)
• Decongestants (pseudoephedrine)
• Phenothiazines (prochlorperazine)
• TCAs (amitriptyline)
• Caffeine
• Diuretics
• SNRIs
• Testosterone products
Evaluation:
Patient Questionnaires:
• AUA Symptom Index (AUA-SI) and International
Prostate Symptom Score (I-PSS)
• Nearly identical, validated, short self-administered
questionnaires
• Used to assess the severity of symptoms
• Treatment decisions
• Used as a monitoring tool
• BPH Impact Index (BII)
• Questionnaire assess the effect of symptoms on
everyday life
• Treatment decisions
Diagnosis:
Symptoms:
• Lower Urinary Tract Symptoms (LUTS)
• Static/Dynamic
• Hesitancy
• Straining
• Weak stream
• Full sensation
• Pain
• Post-void dribbling
• Detrusor
• Frequency
• Urgency
• Nocturia
• Symptoms can be similar to prostate cancer
• All patients should be referred to a physician prior to
starting treatment
Diagnosis:
Physical Exam:
• Digital Rectal Exam (DRE)
• Determines size of prostate
• Can identify any lumps or nodules
• BUN/SCr
• To check kidney function
• Urinalysis and Serum Prostate-Specific Antigen
(PSA)
• These are used to rule out conditions other than BPH
• PSA should be used with caution
Prostate-Specific Antigen (PSA):
PSA recommended if:
• Cancer risk factors
• Advanced age
• Family history of prostate cancer
• African American
• Age ≥ 40
• ≥ 10 years life expectancy
• Potential benefit > cost to the patient

PSA Results:
• < 4 ng/mL = normal
• 4 - 10 ng/mL = intermediate
• > 10 ng/mL = high (may need further evaluation)
Treatment Principles:
Non-Pharmacologic Therapy:
Watchful Waiting: (Patient Specific)
• Active surveillance is recommended for men who begin with
mild symptoms related to BPH that have not begun to affect
daily quality of life.
• Discuss further treatment options along with the risks and
benefits with each medication. Should Identify a treatment
of choice with shared decision making.
• May resolve over months → years
Lifestyle Modifications:
• Nightly fluid restriction
• Timed bladder voiding and double-voiding techniques
• Pelvic floor exercises
• Regular physical activity
• Treatment of constipation
• Avoiding caffeine, alcohol, and highly seasoned or irritative
foods.
D/C or minimize offending medications
Reassess every 6-12 months
Initial Therapy: Mod-Severe (Medications)

Follow-up every 1-6 months

• Disease symptoms, progression, complications
Goal: Relief of symptoms (Patient should achieve an AUA score
of 3-6 points)
• If not, then titrate doses
• Combination therapy
• Urology referral
Natural Products:
Saw Palmetto
• MOA: 5-ARi, anti-inflammatory, anti-proliferative
• Inconsistent data, could be efficacious in early onset for
patients with mild symptoms
• ADE: HA, nausea, dizziness
Pygeum, pumpkin seed (beta-sitosterol), rye pollen
Lycopene
• Used for prostate cancer prevention
• No evidence for use in BPH
Pharmacist should not recommend the use of natural products
until the patient has seen a healthcare provider
Alpha-Antagonist: Overview
Place in therapy:
• 1st line therapy: most effective
Mechanism of Action:
• Relieve voiding symptoms by relaxing prostate smooth muscle → dilation of
arterioles and veins within the prostate
Side Effects:
• Orthostatic hypotension (1st dose phenomenon)
• Syncope, dizziness
• Reflex tachycardia, QT prolongation
• Fluid retention
• ED/abnormal ejactulation
Dosing:
• Daily, titrate slowly over several weeks
• Must taper if discontinuing
Warnings
• IFIS, angina/CAD, falls, arrhythmias
Monitoring
• BP, HR, symptom score
Counseling
• Orthostatic hypotension, sexual adverse effects
Alpha-Antagonists: Specifics
Intraoperative Floppy Iris Syndrome (IFIS)
Cataract Surgery → IFIS risk
• Most common with tamsulosin
• Deficient muscle tone
• Other alpha antagonist - case reports
• Counseling:
• Ask patients about cataracts when starting tamsulosin
• Other agents may be a better option - discuss with
ophthalmologist
• Holding tamsulosin has shown no benefit
• Modification of surgical techniques
• Atropine drops two days prior to surgery

Have the patient tell their ophthalmologist so they can take

appropriate action
Alpha-Antagonist: Combination Therapy
Standard combinations include:
• Alpha-Antagonist + 5𝞪-Reductase Inhibitors
• Studies have shown statistically significant reductions in parameters
of clinical progression with combination approaches over
monotherapy.
• Alpha-Antagonist + anticholinergic/antimuscarinic therapy
• IPSS improvement variable
• Tolterodine (Detrol) 1-4 mg PO daily
• Fesoterodine (Toviaz) 4-8 mg PO daily
• Oxybutynin ER (Ditropan XL) 5-10 mg PO daily
• Alpha-Antagonist + beta-3-agonists (Mirabegron)
• Mechanism of action: activates beta-3 adrenergic receptors in the
bladder resulting in relaxation of the detrusor smooth muscle during
the urine storage phase, thus increasing bladder capacity.
• Dosing: Initial: 25 mg PO once daily. May increase to 50 mg once daily
after 4 to 8 weeks based on response and tolerability.
5𝞪-Reductase Inhibitors: Overview
Place in therapy:
• Alone or in combination with alpha-antagonist
• May delay progression if prostate > 40 g
Mechanism of Action:
• Blocks 5𝞪-Reductase enzyme thus decreasing concentrations of
DHT. Blocks the growth of prostate cells. Improves symptoms but
may take up to 6 months
Side Effects: (Mild, transient)
• Decrease labido, ED/abnormal ejactulation
• Mastalgia
Dosing:
• Daily, no need to titrate/taper
Warnings
• Pregnancy X, breast cancer (rare)
Monitoring
• PSA every 6 months, symptom score, prostate size
Counseling
• Sexual ADE, tablet shell in stool
5𝞪-Reductase Inhibitors: Specifics
Dutasteride (Avodart)
• Dosing:
• 0.5 mg by mouth once daily
• Pearls:
• High cost
Finasteride (Proscar)
• Dosing:
• 5 mg by mouth once daily
• Pearls:
• Low cost
Clinicians may consider 5-ARis as a treatment
option to reduce intraoperative bleeding
5𝞪-Reductase Inhibitors: Combination Therapy

5-ARI in combination with an alpha blocker

should be offered as a treatment option only to
patients with LUTS associated with demonstrable
prostatic enlargement as judged by:

• A prostate volume of >30 cc on imaging,

• A PSA > 1.5 ng/dL,
• Or palpable prostate enlargement on DRE
Phosphodiesterase Inhibitors (PDE-5)
Tadalafil (Cialis)
Place in therapy:
• For patients with LUTS/BPH irrespective of comorbid ED, tadalafil 5 mg
should be discussed as a treatment option.
Mechanism of Action:
• Decreases detrusor, prostate and urethra smooth muscle tone.
• Can improve LUTS, but not urinary flow rate
Side Effects:
• Back pain, Flushing, Headache, orthostasis
• Dyspepsia, Myalgia, pharyngitis, hearing loss
Dosing:
• 5 mg daily
Warnings
• Contraindicated if CrCl < 30 mL/min
Monitoring
• BP, HR, hearing, symptoms
Counseling
• Headache, orthostasis, other indications
PDE-5 (Tadalafil): Combination Therapy
Clinicians should not offer the combination of
low-dose daily 5mg tadalafil with alpha blockers
for the treatment of LUTS/BPH

This combination offers no advantages in

symptom improvement over either agent alone
Surgery
Minimally invasive:
• TUNA, TUMT
• Both use heat to decrease size of
prostate
• Efficacy
• Higher reoperation rate
• Safety
• Less complications
Invasive:
• TURP, open prostatectomy
• Removal of the prostate
• Efficacy
• Most effective
• Safety
• Highest complication rate
Summary and tips:
• Use objectives as a guide
• Consider each medications characteristics and
relate these to how to manage patients
• In case-based questions: think about each
sentence, what is being given to you in terms of
criteria for selecting therapy, counseling points
• Remember what medications can worsen BPH
• Test questions will predominantly be designed
in real-life scenarios
References
1. Prostate Enlargement (Benign Prostatic Hyperplasia). (2022, July 23).
National Institute of Diabetes and Digestive and Kidney Diseases.
https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-probl
ems/prostate-enlargement-benign-prostatic-hyperplasia
2. Lerner LB, McVary, KT, Barry MJ et al: Management of lower urinary tract
symptoms attributed to benign prostatic hyperplasia: AUA Guideline part I,
initial work-up and medical management. J Urol 2021; 206: 806.
3. Debevec-Mckenny, E., Gillespie, S., & Chessen, K. (2022). Benign prostatic
hyperplasia. Osmosis. Retrieved March 19, 2023, from
https://www.osmosis.org/learn/Benign_prostatic_hyperplasia
4. Ng M, Baradhi KM. Benign Prostatic Hyperplasia. [Updated 2022 Aug 8]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023
5. Prostate Cancer: Screening. (2018, May 8). United States Preventative
Service Task Force.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prosta
te-cancer-screening
6. Multiple Entries. Lexi-Drugs. Lexi-Comp Online. Lexicomp, Inc. Hudson, OH.
Available at: http://online.lexi.com/crlonline. Accessed March, 10th, 2023
https://forms.gle/D78c8PD9bgdwoGDW8

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