dysfunction, one should NOT give him:

a.low-dose sildenafil.

b.low-dose vardenafil.

c.low-dose tadalafil.

d.MUSE.

e.a vacuum pump.

.The amount spent on phytotherapy for the treatment of BPH is estimated to be:

a.$10 million.

b.$100 million.

c.$1 billion.

d.$10 billion.

.The definitive mechanism of action for Serenoa repens is:

a.inhibition of 5α-reductase.

b.inhibition of cyclooxygenase.

c.inhibition of lipoxygenase.

d.inconclusive.

.Potential future therapeutic avenues in BPH pharmacotherapy include:

a.nitric oxide donors.

b.α-adrenoceptor agonists.

c.HMG coenzyme A inhibitors.

d.endothelin antagonists.

Answers

1.d. Transition zone and periurethral zone. The proliferative process originates in the transition zone and the periurethral glands.

2.a. Serum prostate-specific antigen (PSA). A strong correlation exists between serum PSA levels and prostate volume.

3.b. α-adrenergic agonists. Current prescription and over-the-counter medications should be examined to determine whether the patient is taking drugs that impair bladder contractility (anticholinergics) or that increase outflow resistance (α-sympathomimetics).

4.c. Identify prostate nodules. The DRE and neurologic examination are done to detect prostate or rectal malignancy, to evaluate anal sphincter tone, and to rule out any neurologic problems that may cause the presenting symptoms.

5.a. Urinalysis. In older men with BPH and a higher prevalence of serious urinary tract disorders, the benefits of an innocuous test such as urinalysis

clearly outweigh the harm involved.

6.c. Renal ultrasound. An elevated serum creatinine level in a patient with BPH is an indication for imaging studies (ultrasonography) to evaluate the upper urinary tract.

7.c. 30%. Twenty-eight percent of men with histologically proven BPH have a serum PSA level greater than 4.0 ng/mL.

8.a. LUTS. The International Prostate Symptom Score (I-PSS), which is identical to the AUA Symptom Index, is recommended as the symptom scoring instrument to be used for the baseline assessment of symptom severity in men presenting with LUTS. When the I-PSS system is used, symptoms can be classified as mild (0 to 7), moderate (8 to 19), or severe (20 to 35). The I-PSS cannot be used to establish the diagnosis of BPH.

9.d. Refractory gross hematuria secondary to BPH. Surgery is recommended if the patient has refractory urinary retention (at least one failed attempt at catheter removal) or any of the following conditions, clearly secondary to BPH: recurrent urinary tract infection, recurrent gross hematuria, bladder stones, renal insufficiency, or large bladder diverticula.

.d. b or c. One study found that flow rate recording cannot distinguish between bladder outlet obstruction and impaired detrusor contractility as the cause for a low Qmax.

.a. Repeat the PVR assay. Residual urine volume measurement has significant intraindividual variability that limits its clinical usefulness.

.a. 10%. One study recommended invasive urodynamic testing for patients with a Qmax higher than 15 mL/sec. For the population in their study, this would have resulted in an additional 9% of patients being excluded from surgery and a decrease in failure rate to 8.3%.

.c. 60%. Overactive contractions are present in about 60% of men with LUTS and correlate strongly with irritative voiding symptoms.

. c. Likely. UDCs resolve in most patients after surgery.

.e. None of the above. Bladder trabeculation may predict a slightly higher failure rate in patients managed by watchful waiting but does not predict the success or failure of surgery.

.b. Urinalysis demonstrating hematuria. Upper urinary tract imaging is not recommended for routine evaluation of men with LUTS unless they also have one or more of the following: hematuria; urinary tract infection; renal insufficiency (ultrasonography recommended); history of

urolithiasis; and history of urinary tract surgery.

.b. Moderate. The group mean changes in AUA Symptom Index for subjects rating their improvement as markedly, moderately, or slightly improved, unchanged, or worse were − 8.8, − 5.1, − 3.0, − .7, and + 2.7, respectively.

.e. None of the above. Urodynamic testing does not predict symptom improvement after α-adrenergic blockade, transurethral microwave

thermotherapy, or prostatectomy.

.d. Neither a nor b. One study reported no correlation between the AUA symptom score and PVR volume. There are also no data documenting that the incidence of UTI is related to PVR volume.

.b. 15 cm H2O. The definition of detrusor instability is the development of a detrusor contraction exceeding 15 cm H2O at a bladder volume less than

or equal to 300 mL.

.d. 80%. Of 59 Danish patients presenting to an emergency department with acute retention, 73% had recurrent urinary retention within 1 week after removal of the catheter.

.e. All of the above. The incidence of acute urinary retention was related to age, severity of symptoms, and size of the prostate gland.

.b. A placebo-controlled double-blind design. The only mechanism to ensure that the potential bias of the subject and the investigator does not influence the outcome is a randomized double-blind placebo-controlled design.

.a. Less treatment effect required to achieve statistical significance. The larger the number of subjects enrolled in a study, the smaller the change required to achieve statistical significance.

.d. All of the above. The attractive feature of medical therapy relative to prostatectomy is that clinically significant outcomes are obtained with fewer, less serious, and reversible side effects.

.b. 50%. A 55% reduction in transurethral prostatectomy has occurred despite the progressively increasing number of men enrolled in the Medicare

program.

.c. 30%. Approximately 30% of American men older than 50 years of age have moderate to severe symptoms.

.d. Bothersome. The ideal candidate for medical therapy should have symptoms that are bothersome and have a negative impact on the quality of life.

.d. 40%. Smooth muscle is one of the dominant cellular constituents of BPH, accounting for 40% of the area density of the hyperplastic prostate.

.a. α1 receptor. The tension of prostate smooth muscle is mediated by the α1 adrenergic receptors.

.a. Its longer half-life. Terazosin and doxazosin are long-acting α-adrenergic blockers that have been shown to be safe and effective for the treatment of

BPH.

.a. α1a. Prostate smooth muscle tension has been shown to be mediated by the α1a adrenergic receptors.

.d. None of the above. The relationships between percent change in total symptom score and peak flow rate versus baseline age, prostate size, peak flow rate, PVR volume, and total symptom score were examined to identify clinical or urodynamic factors that predicted response to terazosin therapy. No significant association was observed between treatment effect and any of these

baseline factors.

.b. 4. The treatment-related improvement (terazosin minus placebo) in the AUA symptom score and urinary peak flow rate was 1.4 mL/sec and 3.9 symptom units, respectively.

.b. 42. The initial improvements in symptom scores and peak flow rate in 450 subjects were maintained for up to 42 months.

.c. Tamsulosin. The advantage of not lowering blood pressure in men who are hypertensive at baseline is controversial.

.d. Tamsulosin. The treatment-related incidences of asthenia, dizziness, rhinitis, and abnormal ejaculation observed for 0.4 mg of tamsulosin were 2%, 5%, 3%, and 11%, respectively, and for 0.8 mg of tamsulosin were 3%, 8%, 9%, and 18%, respectively.

.c. 30%. Approximately 30% of men treated for BPH have coexisting hypertension.

.b. Central nervous system. The α1-mediated dizziness and asthenia are likely due to effects at the level of the central nervous system.

.c. No dose titration. The major advantage of 0.4 mg tamsulosin and slowrelease alfuzosin is the lack of requirement for dose titration.

.b. Dihydrotestosterone. The embryonic development of the prostate is dependent on the androgen dihydrotestosterone.

.d. All of the above. The Proscar Long-Term Efficacy and Safety Study (PLESS) represents one of the longest duration multicenter randomized double-blind placebo-controlled studies reported in the literature on medical therapy for BPH. The unique findings of PLESS were related to incidences of both acute urinary retention and surgical intervention for BPH. The risk

reduction of acute urinary retention and BPH-related surgery was clinically relevant, especially in men with very large prostates.

.c. Transurethral prostatectomy. These preliminary observations have been confirmed by a randomized, double-blind placebo-controlled study

demonstrating that finasteride prevents recurrent gross hematuria secondary to BPH after prostatectomy.

.a. Is a dual inhibitor of type 1 and type 2 5α-reductase. Unlike finasteride, which only inhibits the type 2 isoenzyme.

.a. Breast tenderness. The incidences of breast tenderness and diarrhea in the flutamide group were 53% and 11%, respectively.

.b. Ability to titrate the level of androgen suppression. A potential advantage of a gonadotropin-releasing hormone antagonist over the luteinizing hormone-

releasing hormone agonists in the treatment of BPH is the ability to titrate the level of androgen suppression.

.d. All of the above. In the study, the mean group differences between terazosin versus placebo and terazosin versus finasteride for all of the outcome measures other than prostate volume were highly statistically significant. Terazosin was more effective than finasteride in those subjects with large prostates.

.d. A combination of an α-adrenergic blocker and a 5α-reductase inhibitor is the most effective way of preventing BPH progression. This was the key conclusion of the important MTOPS study that looked at finasteride versus doxazosin versus a combination of both and placebo in men with symptomatic BPH.

. c. Both of the above.

.c. May be reduced to dutasteride alone in 80% of patients with a baseline IPSS less than 20, after 6 months’ treatment. As shown in the study by

Barkin and colleagues (2003).*

. e. All of the above.

.b. No, only in men with large and persistent residual urine volumes.

Antimuscarinics are only contraindicated if there is a large residual urine volume, as such men have a higher risk of retention.

. b. Surgical therapy.

. e. None of the above.

. e. All of the above.

.c. Low-dose tadalafil. The manufacturers of tadalafil recommend avoiding using it with doxazosin. However, care should be taken with the addition of

any PDEI to men already optimized on an α-blocker, as there is an increased risk of symptomatic hypotension in all men being considered for this combination.

.c. $1 billion. Use of these agents in the United States and throughout the world has escalated. It has been estimated that more than $1 billion was spent in the United States alone for these products.

.d. Inconclusive. Although experimental data have suggested numerous possible mechanisms of actions for the phytotherapeutic agents, it is

uncertain which, if any, of these proposed mechanisms is responsible for the clinical responses.

.d. Endothelin antagonists. Although currently untested, endothelin antagonists represent a possible therapeutic avenue in BPH.

Chapter review

1.Patients with severe irritable symptoms and dysuria or microscopic hematuria should have a urine cytology.

2.Surgery is generally recommended for patients with refractory urinary retention, recurrent urinary tract infections, recurrent gross hematuria, bladder stones, renal insufficiency, and large bladder diverticula.

3.Flow rates are inaccurate if the voided volume is less than 150 mL. A peak flow rate (PFR) is better than an average flow rate.

4.Patients with a PFR greater than 15 mL/sec are less likely to have good treatment outcomes after prostatectomy. Patients with a flow rate less than 10 mL/sec have better surgical outcomes.

5.It takes at least a 3-point change in the IPSS for the patient to perceive a difference.

6.Conservative therapy to reduce the severity and bother of symptoms involves decreasing fluid intake, especially before bedtime, moderating alcohol and caffeine intake, and maintaining timed voiding schedules.

7.α-Adrenergic blockers may influence smooth muscle growth in the prostate. They may induce apoptosis.

8.α-Adrenergic blockers may induce the floppy iris syndrome, and patients should be warned of this if they are to have cataract surgery.

9.The maximal reduction in prostate volume requires 6 months after initiation of androgen suppressive therapy.

10.The rationale for aromatase inhibition is that estrogens may be involved in the pathogenesis of BPH.

11.Finasteride reduces prostate volume by approximately 20%. Maximum reduction in prostate volume following androgen deprivation occurs by 6 months.

12.Anticholinergic receptor blockers may be safely administered in patients with bladder outlet obstruction to reduce frequent voiding if they have PVR urine volumes less than 200 mL and do not report increasing hesitancy and show signs of increasing PVR urine volume when placed on such therapy.

13.Phosphodiesterase inhibitors have been known to improve IPSS scores. Phosphodiesterase inhibitors do not improve flow rate.

14.Concomitant use of α-adrenergic blockers and phosphodiesterase inhibitors may lead to hypotension.

15.Mortality increases sixfold in patients with renal insufficiency who are treated surgically for BPH.

16.PSA is of value in predicting the likelihood of response to 5α-reductase inhibitors and the risk of LUTS/BPH progression.

17.PSA is reduced by one-half in patients on 5α-reductase inhibitors.

18.The value of pressure flow studies and PVR in predicting the outcome of treatment is uncertain.

19.There is no convincing evidence in the aging male that an elevated PVR causes recurrent UTIs.

20.An elevated serum creatinine level in a patient with BPH is an indication for imaging studies (ultrasonography) to evaluate the upper urinary tract.

21.Overactive contractions are present in approximately 60% of men with LUTS and correlate strongly with irritative voiding symptoms.

22.Upper urinary tract imaging is not recommended for routine evaluation of men with LUTS unless they also have one or more of the following: hematuria; urinary tract infection; renal insufficiency (ultrasonography recommended); history of urolithiasis; and history of urinary tract surgery.

23.The definition of detrusor instability is the development of a detrusor contraction exceeding 15 cm H2O at a bladder volume less than or equal

to 300 mL.

24.Finasteride prevents recurrent gross hematuria secondary to BPH after prostatectomy.

25.A combination of an α-adrenergic blocker and a 5α-reductase inhibitor is the most effective way of preventing BPH progression.

* Sources referenced can be found in Campbell-Walsh Urology, 11th Edition, on the Expert Consult website.