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

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
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
0+ 1 2 3 4 5
after you
finished
urinating?
Over
the past
month, how
often have
you had to
urinate again

less than 2 h
after you
finished
urinating?
0 1 2 3 4 5
Over
the past
month, how
often have
you found you
stopped and
0 1 2 3 4 5
started again
several times
when you
urinated?
Over
the past
month, how
often have
you found it
difficult to
postpone
urination?
0 1 2 3 4 5
Over
the past
month, how
often have

you had a
weak urinary
stream?
0 1 2 3 4 5
Over
the past
month, how
often have
you had to
push or strain
to begin
urination?
0 1 2 3 4 5
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)
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 M
ed 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]