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

Benign and Malignant Diseases of the Prostate Part 11 Benign Disease Symptoms Benign proliferative disease may produce hesitancy, intermittent voiding, a diminished stream, incomplet

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

not occur

Table 91-2 AUA Symptom Index

AUA Symptom Score (Circle 1 Number on Each Line)

Questi

ons to Be

Answered

Not

at All

Le

ss than 1 Time in

5

Le

ss than Half the Time

Abo

ut Half the Time

Mo

re than Half the time

Alm ost Always

Over

the past

month, how

often you

have had a

sensation of

not emptying

your bladder

completely

after you

finished

urinating?

Over

the past

month, how

often have

you had to

urinate again

less than 2 h

after you

finished

urinating?

Over

the past

month, how

often have

you found you

stopped and

several times

when you

urinated?

Over

the past

month, how

often have

you found it

difficult to

postpone

urination?

Over

the past

month, how

often have

you had a

weak urinary

stream?

Over

the past

month, how

often have

you had to

push or strain

to begin

urination?

Over

the past

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

(No ne)

(1 time)

(2 times)

(3 times)

(4 times)

(5 times)

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

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]