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LEARNING OBJECTIVES

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LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Explain the pathophysiologic mechanisms underlying the symptoms and signs of benign prostatic hyperplasia (BPH).

  2. Recognize the symptoms and signs of BPH in individual patients.

  3. List the desired treatment outcomes for a patient with BPH.

  4. Identify factors that guide selection of a particular α-adrenergic antagonist for an individual patient.

  5. Compare and contrast α-adrenergic antagonists versus 5α-reductase inhibitors in terms of mechanism of action, treatment outcomes, adverse effects, and interactions when used for management of BPH.

  6. Describe the indications, advantages, and disadvantages for single drug versus combination drug treatment of BPH.

  7. Describe the indications for surgical intervention of BPH.

  8. Formulate a monitoring plan for a patient on a given drug treatment regimen based on patient-specific information.

  9. Formulate appropriate counseling information for patients receiving drug treatment for BPH.

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KEY CONCEPTS

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  • Image not available. The lower urinary tract symptoms (LUTS) and signs of benign prostatic hyperplasia (BPH) are due to static, dynamic, or detrusor factors. The static factor refers to anatomic obstruction of the bladder neck caused by an enlarged prostate gland. The dynamic factor refers to excessive stimulation of α-adrenergic receptors in the smooth muscle of the prostate, prostatic urethra, and bladder neck. The detrusor factor refers to irritability of hypertrophied detrusor muscle as a result of long-standing bladder outlet obstruction.

  • Image not available. Drug treatment goals for BPH include relieving obstructive and irritative voiding symptoms, preventing complications of disease, and reducing the need for surgical intervention.

  • Image not available. Watchful waiting is indicated for patients with mild symptoms that are not bothersome.

  • Image not available. Single-drug treatment with an α-adrenergic antagonist is preferred for patients with moderate or severe symptoms of BPH. Single-drug treatment with a 5α-reductase inhibitor should be reserved for patients with moderate or severe symptoms and significantly enlarged prostates of at least 30 g (1.05 oz).

  • Image not available. Surgical intervention should be reserved for patients with severe LUTS due to BPH and those with complications of disease, such as recurrent urinary tract infections, recurrent severe gross hematuria, renal failure, and bladder calculi.

  • Image not available. α-Adrenergic antagonists reduce the dynamic factor. They competitively antagonize α-adrenergic receptors, thereby causing relaxation of the bladder neck, prostatic urethra, and prostate smooth muscle. They do not shrink an enlarged prostate. The onset of action is days to weeks, depending on the need for up-titration of the daily dose to achieve a therapeutic response. Dose-limiting adverse effects include orthostatic hypotension and syncope. In addition, delayed or retrograde ejaculation has been reported. Combined use with antihypertensives, diuretics, or phosphodiesterase inhibitors can increase the risk of hypotensive episodes, particularly with immediate release formulations of second-generation α-adrenergic antagonists.

  • Image not available. Among the α-adrenergic antagonists, modified-release alfuzosin is considered functionally uroselective because usual therapeutic doses produce relaxation of the bladder neck and prostatic smooth muscle with minimal peripheral vascular relaxation. Although alfuzosin appears to produce less hypotension than immediate-release formulations of terazosin and doxazosin, it is ...

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