Transcription:

Introduction: The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA category one credit. Position should claim only the credit commensurate with the extent of their participation in this activity.

Melanie Cole: Welcome. This is UF Health Med Ed Cast with UF Health Shands hospital. I'm Melanie Cole and today we're discussing benign prostatic hyperplasia. We're going to understand BPH and its role of causal symptomatology. We're reviewing the epidemiology and treatment modalities in BPH and sharing an evidence based knowledge of current and emerging therapies. Joining me today is Dr. Michael Dennis. He's a Clinical Assistant Professor in the Department of Urology at the University of Florida College of Medicine and the Medical Director at UF Health Shands Hospital in the Department of Urology. Dr. Dennis, it's a pleasure to have you join us today. I'd like to set the stage for other providers. Tell us about the prevalence and incidence of BPH.

Dr. Dennis: Thank you for allowing me to be here today. Benign prostatic hyperplasia or BPH, is one of the most common conditions affecting men. It can lead to a number of symptoms for patients commonly referred to as lower urinary tract symptoms. The BPH was originally benign prostatic hypertrophy, but technically it's a pathologic condition called hyperplasia, meaning an increase in the number of cells in the prostate gland. Typically occurs initially with the first burst of testosterone in the teenage years and then gradually increases with the second peak in the late forties, early fifties and continues on into the nineties

Host: Tell us a little bit about the epidemiology of it, and when you do that you can also tell us about what happens if it's left untreated.

Dr. Dennis: It's a worldwide issue that can affect as many as 40 million men in the United States. It's on an increase because metabolic risk factors such as obesity, it is going to cause symptoms that include urinary frequency, urinary urgency, getting up at night to go to the bathroom, a weakened urinary stream. As this progresses, the patients can be prone to urinary incontinence and urinary tract infections. If it is allowed to persist, the bladder can be damaged. And renal failure could occur.

Host: Such an interesting topic and as you say, because it's so prevalent as a standalone disorder is one thing, but we have to discuss the causal symptomatology. Dr. Dennis, when you say that it's causing all of these other things, tell us a little bit about how that extends out and can even have a domino effect for the man.

Dr. Dennis: First of all, it's important to realize that the prostate is not a donut that sits around a urinary channel. It's actually between the bladder and the urethra, so urine passes through the prostate when a person urinates. As the prostate enlarges, it causes a resistance to outflow of urine from the bladder. This is the first early symptom with perhaps a slowing of the urinary stream or some dribbling of urination. As this progresses, then the bladder has two options. One is to increase its muscular strength to push past this outflow obstruction or it weakens and fails and starts to retain urine, neither of which is a condition we like to see in men with this problem.

Host: Dr. Dennis are primary care clinicians generally, the first point of contact for men who suffer troublesome symptoms of BPH, can they be appropriately managed in the ambulatory setting and what's involved in getting them to see a urologist? It's not easy to get men to see their primary care provider, much less a urologist.

Dr. Dennis: That's an interesting question because there has been an evolution in the male attitudes towards the prostate within previous decades. You could rarely get a man in for any type of prostate exam. Once the PSA became available to test for prostate cancer, men became more accepting to talk about their prostate and to get their prostate checked. You're absolutely right that the primary care provider is the first physician who sees the patient. The difficulty at that level is the evaluation of the patient for BPH. The bladder only has two functions. It stores urine and it empties urine. BPH typically involves more of an emptying of the bladder. However, the symptoms of storage problems can be very similar. I think that in a primary care setting, a good physical exam, a history, a knowledge of the medications the patient is taking and potential side effects on the prostate. A digital exam to check the size of the prostate and perhaps a trial of medication would be the most I would expect a primary care physician to do in his office.

Host: So then when would referral be appropriate if he's not able to manage those symptoms. Tell us a little bit about treatment and when referrals really important.

Dr. Dennis: I think the first thing to realize is that the primary care physician has to make a decision on this being a storage or emptying problem. Assuming that it is an emptying problem, then a trial of medications such as an alpha blocker would probably relieve the early symptoms and he would have a patient who would leave his office very happy. I think that if he cannot determine if it's a storage or emptying problem or if a trial of medication is not resolving the symptoms, then that is the ideal time for the neurologist to begin the evaluation.

Host: So then tell us a little bit about your role. What you would do and some of the treatments that you're looking for, are they to reduce the size of the prostate? Is that even possible? And if not, what are you doing for the symptoms and what's going on as a result?

Dr. Dennis: First of all, from a urology standpoint, one thing that we have available at most primary care physicians do not is the ability to assess whether the problem is a storage or emptying problem. Something as simple as a bladder ultrasound to assess a post-void residual would tell us whether the patient is obstructed. And if he is, that means the prostate has enlarged and is causing the problem. If the patient does not respond to alpha blockade, which is the most common medication, tamsulosin, alphazosin, then it is possible to shrink the prostate with medications called five alpha reductase inhibitors, which actually prevent the conversion of testosterone into dihydrotestosterone, which shrinks the prostate gland.

Host: And what about surgical treatments? Which ones have the most beneficial effects? Are you doing TURP? Are you doing whole lap? Are you doing Euro lift? Tell us some of the things that you're doing.

Dr. Dennis: So interestingly, surgery has been put on the back burner once these medications became available. Recent studies show that the out-of-pocket cost at five years for continuous medication is probably less than the cost of intervention. So the simple answer to your question is in 2020 the transurethral section of the prostate. The TURP is the historical gold standard for treatment of BPH. The more advanced TURP uses a bipolar technique which allows us to operate using saline and eliminates many of the problems that were associated with the older style monopolar TURP. So we do not have a TURP syndrome. We can operate more safely for a longer period of time with this bipolar system. The whole lap, what you bring up is an interesting procedure where the laser is used to essentially find the location between the enlarged prostate and the shell of the prostate, and basically remove that in one piece and then grind it up and remove it from the bladder as opposed to the TURP, which gradually shaves this enlarged prostate away from the shell of the prostate, so to speak.

It's a good procedure. I think it compares favorably with the TURP. It is extremely difficult to learn and is not available outside of major medical centers. Additional procedure available at the University of Florida is a laser ablation of the prostate which goes by the name Greenlight. It is typically performed as an outpatient procedure and results are compare relatively favorably to the bipolar TURP. It is used only for selected configurations of the enlargement of the prostate gland and I think it has a place in care. The last procedure that we are using and the one we are very excited about is called the prosthetic urethral lift, which essentially is putting implants in the prostate to compress the enlarge lobe of the prostate and open up that urinary flow channel through the prostate to relieve the symptoms. This has the advantage of being an outpatient procedure. It's a very short duration procedure, and has about an eighty five percent success rate.

Host: Dr. Dennis, this is really so interesting and as you've been discussing that when medicational treatment fails to elicit that sufficient response when symptoms are severe or there's a concern for complication. Thank you so much for discussing the surgical options. Do men ask you and I assume they're going to ask their providers as well so that you can counsel their providers on how to counsel them about herbal treatments? There are so many on the market and men want to know if they can skip everything we've been talking about and look to some of these herbal treatments.

Dr. Dennis: The problem with supplemental or complimentary medicine is that there is no standard for these drugs in terms of manufacturing and many studies show that what is actually in the pill is not what's on the label for these medications. Having said that, Saw Palmetto Berry extracts, which had been around forever and since I'm in Florida, have to give the Seminole Indians credit for chewing on that Berry to improve urination will improve voiding symptoms in some percentage of men in the thirty to forty percent range. That does not meet the standard of FDA approved medication, which has to reach a sixty five to eighty percent success rate to be approved. If a patient wants to try that medication. I don't think that there is a downside other than not getting the expected result.

Host: Before we wrap up, tell us about any current and emerging therapies that you see down the pike for BPH. What's on the horizon?

Dr. Dennis: There are several things are receiving quite a bit of publicity. One is a prostate artery embolization. We are using this on a case by case basis at the University of Florida for patients with very large prostates who are not candidates for surgical therapy because of coexisting medical conditions. This actually blocks the arterial flow into the prostate and since no blood flow, the prostate tissue actually shrinks and patients are getting a pretty good result in terms of being able to urinate more normally. I think a more exciting new technology is called Aqua ablation, where under computerized and ultrasound guidance, a high pressure jet of water is used to remove the BPH cells from the inside of the prostate gland. The equipment is very expensive. The trials are still ongoing and there is no long-term data, but this appears to be a very exciting application.

Host: Wow. It certainly is. Any final thoughts for other providers on when you feel it's important that they refer to the specialists at UF Health Shan's Hospital if they have patients with BPH?

Dr. Dennis: I think there is One comment I would like to make and that is that prostate size and lower urinary check symptoms do not necessarily correlate. So if a man is having significant symptoms, it's just as important for us to see him with a small prostate as it is with a larger prostate and allow, allow us to make the determination of whether this is something that needs treatment.

Host: That's a very important point. Thank you so much Dr. Dennis for joining us today, and that concludes today's episode of UF Health Med Ed Cast with UF Health Shan's Hospital. To learn more about this and other healthcare topics at UF Health Shan's Hospital, please visit UFHealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other UF Health Shan's Hospitals podcasts. For more health tips and updates, please follow us on your social channels. I'm Melanie Cole.