Recognizing symptoms of an enlarged prostate

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Benign prostatic hyperplasia may cause stenosis of the urethra
Benign prostatic hyperplasia may cause stenosis of the urethra

The prostate gland has two important functions: To produce ejaculatory fluid and to act as a barrier to retrograde UTIs. Prostate enlargement, or benign prostatic hyperplasia (BPH), can produce a constellation of unpleasant symptoms that result when the enlarged gland forces the bladder to work harder to expel urine. The prostatic obstruction is both anatomic (compression of the urethra) and dynamic (increased muscle tone of the prostate and bladder neck). Primary-care nurse practitioners and physician assistants are in an ideal position to recognize and evaluate the symptoms of BPH, review the differential diagnoses, recommend treatment, refer patients as necessary, and ensure follow-up. The Clinical Advisor spoke to Richard J. Macchia, MD, chair of the Department of Urology and a Distinguished Teaching Professor at the SUNY Downstate Medical School in Brooklyn, N.Y., and Ivan Rothman, ARNP, an NP with urology certification at the University of Washington Medical Center Urology Clinic and faculty member at the University of Washington School of Nursing in Seattle. Both clinicians have expertise in BPH, which affects nearly 50% of men aged 50 years and older.

Q: Who is most likely to get BPH?

Dr. Macchia: Any man is susceptible, but with age, an enlarged prostate becomes more and more likely.

Mr. Rothman: Generally, men diagnosed with BPH are older than 40.

Q: Which symptoms besides frequent urination should alert primary-care providers (PCPs) to the possibility of BPH?

Mr. Rothman:
Be on the lookout for any kind of voiding problem. The two main types are irritative and obstructive. Irritative refers to frequency and urgency, and obstructive refers to difficulty starting, slow stream, and post-void dribbling. Waking up at night can be a problem in and of itself and is always worth evaluating. The best office-based diagnostic tools are the symptoms and the score on the American Urological Association (AUA) Symptom Index (SI) (available at www.auanet.org/guidelines/main_reports/bph_management/chapt_1_appendix.pdf, accessed July 8, 2008). This is a well-validated paper-and-pencil screening tool.

Dr. Macchia: Getting the AUA SI score is something any primary-care clinician can do. The patient answers seven self-administered questions about complete voiding, frequency, stopping and starting, urgency, weak stream, straining, and nocturia. Severity of symptoms is quantified by rating each on a scale of 0-5. A man with no symptoms would score 0, and a man with all the symptoms at maximum severity would score 35. When a patient comes to me with lower urinary tract symptoms (LUTS), I ask him to fill out the AUA SI. Any abnormality of urination should trigger the AUA inventory. The International Prostate Symptom Score is similar to the AUA SI.

In addition, ask patients about their “bother” factor: Two patients may have the same symptoms, but one will say, “We have to do something about this; it's driving me crazy,” while the other will tell you it's not a problem.

When patients complain of symptoms, be sure to obtain a complete history because there are many nonurologic causes of LUTS (e.g., diverticulitis). Basically, any pathology in the pelvis can present as LUTS. There is no substitute for a thorough history. Instruct patients to bring in all their medications. It is very difficult to care for patients without knowing what they are taking. What was listed in your notes three months ago is ancient history. In my experience, 30% of patients who state they are on the same medications as at the last office visit are, in fact, not.

After taking the patient's history, I conduct a physical examination with emphasis on the genitalia and prostate. The primary purpose of digital rectal examination (DRE) is to search for any lumps and bumps and to estimate the size of the prostate.

Q: Besides doing a DRE for an enlarged prostate, are there any other office-based diagnostic steps that can be taken?

Mr. Rothman: I always evaluate patients with voiding problems for infection and malignancy. With UTI, look for RBCs, WBCs, and bacteria in the urine. For malignancy, look for hematuria (RBCs).

Dr. Macchia: Dipsticks can be overly sensitive and give false positives for hematuria. I prefer the full urinalysis with microscopic examination, which can show the presence or absence of RBCs, WBCs, bacteria, fungi, and more. It is also important to know what formed elements are in the urine. Formed elements may be an indication that kidney disease is causing the hematuria.

Q: How often should prostate-specific antigen (PSA) be tested?

Dr. Macchia:
After the history, the exam, and the full urinalysis, I discuss with the patient the advisability of measuring his PSA. Generally, I follow the AUA guidelines for PSA testing. It is prudent to follow the guidelines of some national organization. The AUA guidelines are fairly simple: If the patient is African American or has a family history of prostate cancer, he should be getting an annual prostate checkup starting at age 40. If he doesn't fall into either category, start at age 50. While PSA-based true population screening is controversial, what you do in your office with a given patient is straightforward. Failure to discuss the pros and cons of PSA testing with a patient can have unpleasant medical and legal repercussions.

Mr. Rothman: The value of the PSA test is keenly debated. PSA recommendations, which were due to be released by a subcommittee of the AUA in May 2008, have been delayed while members sort through the considerations. Of course, you look at the PSA to screen for prostate cancer. There is no reason you would use it to evaluate voiding dysfunction per se.

Q: When do you order ultrasound or x-rays?

Dr. Macchia: In patients with bothersome or high-score LUTS, I do a simple in-office sonogram to determine whether or not the patient has a significant amount of postvoid residual urine (PVR). In an adult male, we would like to see PVR <100 cc. The PVR is similar to the AUA SI score in that it doesn't give you a diagnosis, only more information, and unindicated testing can lead to considerable misery. In general, a prostate sonogram is performed only in conjunction with a prostate biopsy. Nobody should obtain a sonogram of the prostate unless there is either an elevation of the PSA or a lump or bump found in the prostate.

But some clinicians are ordering prostate sonograms routinely, and like all other tests, sonograms have false positives.

Mr. Rothman: Nonspecific, hypoechoic lesions that are indistinguishable from prostate cancer may show up on prostate ultrasound. One should be wary of ordering prostate ultrasound in men older than 40 without a biopsy.

Q: What signs or symptoms warrant referral to a urologist?

Mr. Rothman: You should refer if the patient has blood in the urine and needs a workup for malignancy. Also refer if one or two attempts at drug therapy have not controlled voiding symptoms to the patient's satisfaction.
Dr. Macchia: Refer any patient with LUTS for which you do not have a specific diagnosis, LUTS you cannot eliminate, an abnormal PSA (based on whatever criteria you use), any abnormality on the rectal exam (especially a lump or bump), or hematuria.
 
Q: What medications are available?

Dr. Macchia: If you think it is likely that the patient has bothersome LUTS or a large PVR attributable to BPH, the first step is to treat with medication. The most commonly prescribed drugs are the alpha blockers tamsulosin (Flomax) and alfuzosin (Uroxatral). I also use the alpha blockers doxazosin (Cardura) and terazosin (Hytrin). By reducing the dynamic outflow obstruction, the strength of the urinary stream can be immediately improved, as can the PVR. Irritability of the bladder can also be decreased over time. One needs to look at both the approved and commonly used off-label dosages for the alpha blockers. I often use higher-than-approved doses of alpha blockers in an attempt to avoid surgery, especially in patients with multiple conditions that raise the risk of morbidity. You must document and advise the patient whenever any medication is used in an off-label manner.
If the prostate is more dramatically enlarged, you can simultaneously start a 5a-reductase inhibitor (e.g., finasteride [Proscar] or dutasteride [Avodart]), which shrinks the prostate. Be aware that these drugs reduce PSA by 50% over time, and this must be taken into account when using PSA to screen for cancer. You really want to max out the pharmacologic therapy before referring for minimally invasive surgery. Many drug companies have informational booklets, and I encourage passing these on to patients.

Mr. Rothman: Alpha blockers are first-line therapy. There is not enough evidence to say one is better than the others. I start with the least expensive or most easily tolerated alpha blocker. If that does not work, change to another one. If you use an alpha blocker with a variable dose, increasing the dose is reasonable. It is also reasonable to add a 5a-reductase inhibitor to an alpha blocker. Most men with BPH are treated by primary-care providers. The AUA SI can be used effectively for monitoring response to therapy. Occasionally, when patients have severe irritative and obstructive symptoms, you may want to add an anticholinergic drug. This is best done in consultation with a urologist. As for nutraceutical supplements, I have seen one study in favor of and one study opposed to saw palmetto. I still recommend trying it; it's safe, easy to obtain, inexpensive, and potentially helpful. It also may help the patient adjust to the idea that he needs to take medication.

Sometimes symptoms of BPH occur in younger men who have never had chronic illness. Patients with BPH need to understand that they have a chronic illness, which needs treatment. The transition to prescription medications can be easier if you start with something OTC.

Q: What lifestyle changes do you recommend?

Dr. Macchia: While there are pathologic conditions that can cause nocturia and must be ruled out, the vast majority of cases are attributable to BPH. I tell patients that when the bladder fills up, they have to go to the bathroom whether it's in the middle of the day or the middle of the night. If they don't want to get up at night, I tell them to start restricting fluid intake four to six hours before going to sleep. I say, “You have the other 18-20 hours of the day to drink all you want.” If people drink fluids at night, especially if they're already well hydrated, their kidneys will put out more and more urine. Alcohol is a special case because it's a diuretic.

A heart-healthy lifestyle is probably good for the prostate. Supplements and minerals are being vigorously promoted, with few data to support their use. However, I recommend patients take a good men's daily multivitamin tablet. Does it work? That's hard to say. The problem with BPH is the 30% placebo rate. Sometimes BPH gets better on its own.

Mr. Rothman: Bus drivers, truck drivers, and airline pilots delay voiding for very long periods of time. This causes the bladder to stretch, become hypocontractile, and lose its ability to function. More frequent urination, when possible, would be beneficial.

Quitting smoking will help reduce prostate size, though we're not sure what the underlying mechanism is.

Q: What are the consequences of untreated BPH?

Dr. Macchia:
Some patients with minimal symptoms might have a large PVR. I have had patients with more than 1,000 cc of residual urine who had no pain or other symptoms. The bladder had become chronically distended and desensitized. If that continues, the bladder loses its compliance. The muscle then becomes more and more inefficient at pushing out urine. Ultimately the muscle becomes a useless piece of tissue.

Mr. Rothman: Acute urinary retention has to be treated with catheterization and frequently with surgery to reduce prostate size. For patients with milder symptomatology though, there is no clear evidence that early treatment will prevent future problems.

Q: What misconceptions about BPH do patients often bring to their PCP?

Dr. Macchia: Far too many patients believe they are going to go back to urinating the way they did when they were in high school. The prostate gland and urinary system get old just like everything else. The symptoms of a vast majority of patients can be improved but not totally eliminated. Also, patients frequently do not realize that stress can cause urinary tract symptoms.

Q: What cautionary advice do you have for PCPs with regard to BPH diagnosis and treatment?

Dr. Macchia:
It is a misconception that only enlarged prostates cause problems and that an enlarged prostate always causes a problem. A small prostate may lead to obstruction and a large one might not. Do not assume LUTS are attributable to BPH or a UTI, and always be careful to rule out a malignancy.

Ms. Lippert is a medical writer and editor in the New York City area.

Read On
* American Urological Association. Diagnosis of BPH. Available at: www.urologyhealth.org/adult/index.cfm?cat=09&topic=173, accessed July 8, 2008.
* American Urological Association. Management of BPH. Available at: www.auanet.org/guidelines/bph.cfm, accessed July 8, 2008.
* Cortlandt Forum. Benign prostatic hyperplasia: applying the guidelines to clinical practice. www.cortlandtforum.com/content/fileadmin/files
/Supplements/PDFs/BPH_CF.pdf, accessed July 8, 2008.

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