Managing the Enlarged Prostate Gland in Elderly Men

Case Presentation

A 67-year-old male is seen in the Emergency Department for urinary retention. He has a history of moderate lower urinary tract obstructive and irritative symptoms consisting of frequency, urgency, poor force and caliber of his urinary stream, and nocturia. In the last few days prior to his admission to the hospital, he had dribbling of urination and lower abdominal pain. A physical exam revealed a bladder palpable above the pubic symphysis, the rectal exam revealed a markedly enlarged prostate gland, and a urinalysis revealed 5-7 white blood cells/high power field. The patient’s prostate-specific antigen (PSA) was 6.5 ng/mL. The blood urea nitrogen (BUN) was 40 mg/dL, and serum creatinine was 2.6 mg/dL. An abdominal ultrasound revealed hydroureteronephrosis with a markedly distended bladder. A Foley catheter was inserted, and he had approximately 900 cc of residual urine. He experienced a post-obstructive diuresis with normalization of his BUN and creatinine levels. A cystoscopy revealed coaptation of the lateral lobes of the prostate and grade 3 trabeculation of the bladder. The patient had GreenLight™ laser treatment of his outlet obstruction and used a catheter for 3 days after the procedure. He was able to void with a good stream and had less than 75 cc of post-void residual. Follow-up BUN and creatinine levels 3 weeks after the GreenLight laser procedure were 15 mg/dL and 1.7 mg/dL.

Discussion

Prevalence and Incidence of BPH
Benign prostatic hyperplasia (BPH) is the proliferation of nonmalignant stromal and epithelial cells in the prostate, which may lead to nodular formation in the periurethral area of the prostate and subsequent partial or complete obstruction of the urethra. Clinical BPH is a diagnosis of lower urinary tract symptoms (LUTS), urinary tract infections (UTIs), or acute urinary retention (AUR) due to the urethral obstruction. BPH progresses linearly with age. According to the National Institutes of Health, there are more than 7.8 million BPH diagnoses made and more than $1 billion in expenditures each year in the United States alone.¹

Histological evidence of BPH emerges after age 30, with a 50% prevalence in men age 50-61 and a 90% prevalence by age 90.² However, it is difficult to predict how many of these cases will progress to clinical BPH. The overall prevalence of clinical BPH (BPH with LUTS) is 10.3%, with a maximum prevalence of 24% by age 80. It is estimated that 45% of nonsymptomatic 46-year-old men with histological BPH will develop LUTS over the next 30 years.³ Other studies have shown that 40% of 55-74–year-old men with BPH have LUTS.⁴

Signs and Symptoms of BPH—Diagnosis
In most males, the prostate gland slowly begins to enlarge around the age of 30, but it is usually asymptomatic until age 50. An enlarged prostate can cause both obstructive (voiding) and irritative (holding) symptoms that decrease a patient’s quality of life. BPH may lead to UTIs and AUR, which may require surgical intervention, but these are often preceded by LUTS. Obstructive symptoms include decreased force of the urinary stream, straining to urinate and hesitancy to initiate urination, interruptions in flow, and the feeling of not emptying the bladder. Irritative symptoms include frequency, nocturia, dysuria, urgency, and urge incontinence.⁵ These symptoms may decrease a patient’s quality of life by interfering with his ability to perform his job, to travel, to attend social engagements, and to get a good night’s sleep. Depending on the individual, only some of these symptoms may be present, and to varying degrees of severity.

A digital rectal exam may reveal an enlarged prostate. An elevated PSA level may also signify an enlarged prostate, among other possible diagnoses, and should be followed by a free PSA determination. Patients may present with azotemia as a result of prostatic obstruction with subsequent post-renal dilatation of the lower urinary tract with hydroureteronephrosis.⁶ In most cases, the hydronephrosis and azotemia resolve with relief of obstruction, as in the case patient presented in this article. These tests can confirm the diagnosis of BPH and should be used in conjunction with a patient’s history in making a diagnosis and in helping to select the appropriate therapy.

Treatment Options
The average cost for medical treatment of BPH per individual is $1536 per year.¹ There are several treatment options for men with BPH. For those men who experience only mild symptoms, it may be acceptable to consider watchful waiting, which consists of an annual symptom check, a digital rectal exam, and a PSA test.

Medical Management. For those patients with moderate symptoms that interfere with quality of life, medical management is the first line of therapy. The most commonly used medications are alpha blockers and 5-alpha reductase inhibitors (5-ARIs).

Alpha blockers (also known as alpha-1 adrenergic antagonists) include doxazosin, terazosin, tamsulosin, alfuzosin, and silodosin. They work by relaxing smooth muscle in the bladder neck and prostate stroma, which decreases the compression of the urethra, making it easier for the patient to urinate.⁷ These medications rapidly improve symptoms of nocturia, hesitancy, and intermittent urine flow, often within 2 weeks of initiating therapy. However, they fail to reduce prostate size and so are considered only symptom-reducing treatments and do not slow the progression of the disease itself.⁸ Side effects include postural hypotension—which is important to mention to the patient—as well as nasal congestion, weakness, dizziness, and ejaculatory changes such as retrograde ejaculation.⁹

5-ARIs finasteride and dutasteride reduce dihydrotestosterone (DHT) without reducing testosterone levels by inhibiting 5-alpha reductase, an enzyme that converts testosterone to DHT.⁷ 5-ARIs have been shown to reduce prostate size by 20-30% over several months.¹⁰ This reduction in prostate volume not only improves peak urinary flow rates and LUTS, but also decreases AUR rates and the likelihood of a patient needing surgical interventions for BPH.¹¹ The side effects of 5-ARIs occur in fewer than 5% of patients and include gynecomastia, erectile dysfunction, loss of libido, and ejaculatory dysfunction.¹² It is important to note that 5-ARIs decrease the PSA level by 50% after 6 months of therapy.¹³

The use of these two types of drugs in combination has been shown to be significantly more effective than either drug alone.^1,8 In a study by McConnell et al,⁸ clinical progression of BPH was reduced by 66% with combination therapy as compared to 39% with doxazosin alone and 34% with finasteride alone. It should be noted that the risk of AUR and surgical intervention were significantly reduced by finasteride alone or by combination of finasteride and doxazosin, but not doxazosin alone, particularly in high-risk groups.⁸ It should also be noted that in the Prostate Cancer Prevention Trial, men (> 55 yr, low risk of prostate cancer) assigned to take finasteride were shown to have an absolute risk reduction of prostate cancer of 6% and a relative risk reduction of 25% over 7 years.¹⁴

Surgery and Minimally-Invasive Therapy. Patients with BPH who have recurrent UTIs, recurrent hematuria, urinary retention, enlarged prostate volumes of 30-100 mL, or severe symptoms that do not respond to medical treatment may require either surgery or minimally-invasive therapy. There are several invasive surgical options such as prostatectomy, but the standard for surgery today is transurethral resection of the prostate (TURP), with about 200,000 performed each year in the United States.¹⁵

Men looking for a safe and effective treatment for BPH and its associated symptoms should also consider the several minimally-invasive therapies that are available today. Minimally-invasive therapies include laser ablation (ie, GreenLight laser), transurethral needle ablation, transurethral microwave therapy (TUMT), high-energy focused ultrasound, and hot water thermotherapy.¹ TUMT, which is one of the most common minimally-invasive therapies for BPH, uses microwave energy to deliver heat to the prostate via a urethral catheter. It causes cell death and decreases prostatic volume.¹⁵ The procedure is done in an outpatient or office setting using local anesthesia and takes less than an hour. Minimally-invasive treatments provide an alternative for high-risk patients who are unable to tolerate surgery or general anesthesia.

Summary

BPH is a common medical condition that affects most men in the geriatric age group. While BPH does cause unpleasant symptoms that may affect quality of life, there are many treatment options available today that can relieve these symptoms. Whether to choose watchful waiting, medical management, minimally-invasive therapy such as TUMT, or a surgical procedure depends both on the patient’s preference and factors such as age and severity of symptoms. There are effective treatment options, and most men will have a significant improvement in the quality of their lives.

The authors report no relevant financial relationships.

Ms. Janeway is a pre-med student, and Dr. Baum is Clinical Associate Professor of Urology, Tulane Medical School, New Orleans, LA.

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