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

Benign DiseaseSymptoms 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 orinduration. 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) Chapter 091. Benign and Malignant Diseases of the Prostate (Part 11) Benign Disease Symptoms Benign proliferative disease may produce hesitancy, intermittent voiding, adiminished stream, incomplete emptying, and postvoid leakage. The severity ofthese symptoms can be quantitated with the self-administered AmericanUrological Association Symptom Index (Table 91-2), although the degree ofsymptoms does not always relate to gland size. Resistance to urine flow reducesbladder compliance, leading to nocturia, urgency, and, ultimately, urinaryretention. An episode of urinary retention may be precipitated by infection,tranquilizing drugs, antihistamines, and alcohol. Prostatitis often produces pain orinduration. Typically, the symptoms remain stable over time and obstruction doesnot occur. Table 91-2 AUA Symptom Index AUA Symptom Score (Circle 1 Number on Each Line) Questi Not Le Le Abo Mo Almons to Be at All ss than 1 ss than ut Half re than ost AlwaysAnswered Time in Half the the Time Half the 5 Time time Over 0+ 1 2 3 4 5the pastmonth, howoften youhave had asensation ofnot emptyingyour bladdercompletelyafter youfinishedurinating? Over 0 1 2 3 4 5the pastmonth, howoften haveyou had tourinate againless than 2 hafter youfinishedurinating? Over 0 1 2 3 4 5the pastmonth, howoften haveyou found youstopped andstarted againseveral timeswhen youurinated? Over 0 1 2 3 4 5the pastmonth, howoften haveyou found itdifficult topostponeurination? Over 0 1 2 3 4 5the pastmonth, howoften haveyou had aweak urinarystream? Over 0 1 2 3 4 5the pastmonth, howoften haveyou had topush or strainto beginurination? Over (No (1 (2 (3 (4 (5the past ne) time) times) times) times) times)month, howmany timesdid you mosttypically getup to urinatefrom the timeyou went tobed at nightuntil the timeyou got up inthe morning? Sum of7 circlednumbers(AUASymptomScore): ____ 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 thegland, while those with an inability to urinate, gross hematuria, recurrent infection,or bladder stones may require surgery. In patients with symptoms, uroflowmetrycan identify those with normal flow rates who are unlikely to benefit from surgeryand those with high postvoid residuals who may need other interventions.Pressure-flow studies detect primary bladder dysfunction. Cystoscopy isrecommended if hematuria is documented and to assess the urinary outflow tractbefore 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-adrenergicblockers. Finasteride (10 mg/d PO) and other 5α-reductase inhibitors that blockthe conversion of testosterone to dihydrotestosterone decrease prostate size,increase urine flow rates, and improve symptoms. They also lower baseline PSAlevels by 50%, an important consideration when using PSA to guide biopsyrecommendations. α-Adrenergic blockers such as terazosin (1–10 mg PO atbedtime) act by relaxing the smooth muscle of the bladder neck and increasingpeak urinary flow rates. No data show that these agents influence the progressionof the disease. Surgical approaches include TURP, transurethral incision, or removal ofthe gland via a retropubic, suprapubic, or perineal approach. Also utilized areTULIP (transurethral ultrasound-guided laser-induced prostatectomy), stents, andhyperthermia. Further Readings Loblaw DA et al: Initial hormonal management of androgen-sensitivemetastati ...