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BPH (Treatment (surgery (TURP (endoscopic resectoscope inserted through…

- - - - block receptors to relax smooth muscle of the prostate and bladder neck to improve bladder emptying
        
        2nd generation
        
        Prazosin, terazosin, doxazosin, alfuzosin
        
        nonselective for alpha-1 receptors
        
        Result in 1st dose syncope and orthostatic hypotension
        ER doxazosin and alfuzosin produce less hypotension
        
        3rd generation
        
        inhibit alpha-1A adrenergic receptors
        
        Avoid tamsulosin with sulfa allergy
        
        should be taken 30 min after the same meal every day to limit risk of hypotension
        
        Silodosin
        
        much more selective for 1A than tamsulosin
        
        not any more effective than tamsulosin
        
        More ejaculatory disorders as AE because of increased selectivity
        
        dose reduce in CrCl 30-50ml/min
        
        take at same time everyday 30 minutes after food since food decreases their bioavailability
        
        Side effects
        
        asthenia, anejaculation, retrograde ejaculation, flu symptoms, nasal congestion
        
        floppy iris syndrome with doxazosin, silodosin, tamsulosin
        
        DDI with CYP3A4 inhibitors
    - - 5 mg/day tadalafil
      - may cause more risk for hypotension when used with alpha adrenergic antagonists and studies have shown no benefit of combination vs alpha-1 antagonist alone
      - can be used along with 5alpha-reductase inhibitors to offset sexual dysfunction side effect
  - - - finasteride
        
        competitively inhibits Type II 5alpha-reductase, suppressing intraprostatic DHT by 80-90%
      - dutasteride
        
        non-selective inhibitor, so it more quickly suppresses intraprostatic DHT, but also has a bigger effect on serum DHT
      - indicated for moderate-severe BPH disease for those with enlarged prostate glands
      - often given with a 6-month course of alpha1-adrenergic antagonists for acute relief of symptoms before onset of 5alpha-reductase inhibitor
      - disadvantages include:
        delayed peak onset (6-12 months)
        less objective symptom improvement
        more sexual dysfunction
      - in general, decrease the risk of prostate cancer in high risk patients
      - pregnancy category X
      - reduce PSA by about 50%, so double the value you get to interpret a true value
  - - - M3 uroselective anticholinergic agents still cause other SE
        
        darifenacin (M3 uroselective)
        solifenacin (M3>than other receptors)
        transdermal oxybutynin (not M3 uroselective but bypasses 1st pass metabolism to active anticholinergic metabolite)
        ER tolerodine (lower peak plasma concentrations)
      - added to alpha-adrenergic antagonist regimen when irritative voiding symptoms are bad
      - work to decrease urinary frequency, urgency, and incontinence
      - do not improve AUA symptom score or urinary flow rate
      - watch use in elderly due to CNS effects
      - MUST check PVR before starting
        has to be <100-150 mL
        avoiding acute urinary retention
    - - mostly B3 receptors in bladder
        stimulation = increase cAMP which relaxes the detrusor muscle
      - reduces irritative voiding symptoms, increases urinary bladder capacity, and increases interval btn voidings
      - also doesn't affect urinary flow rate BUT it doesn't affect PVR either --> better tolerated than anticholinergics
      - not FDA approved for BPH (approved for overactive bladder) so is considered an alternative to anticholinergics
      - 25 mg daily dose
  - - - Reassess in 6-12months
  - - - gold standard
    - - endoscopic resectoscope inserted through the urethra is used to remove the inside core of the prostatic adenoma.
      - improves AUA sx score by 10-18 points
      - common complication: retrograde ejaculation (up to 75% of pts)
    - - in short term TUIP is as effective as TURP but requires less operation time, causes less blood loss, and produces fewer adverse effects