Case 058: Benign Prostatic Hyperplasia

PATIENT PRESENTATION

Chief Complaint

Urgency and nocturia 4-5 times a night. “My medications do not seem to be working as well as they used to.”

History of Present Illness

This patient has benign prostatic hypertrophy (BPH) and has been taking tamsulosin 0.8 mg PO daily and finasteride 5 mg PO daily for at least two years. However, the patient now feels that his medications are not working, and he has to wear pads in his underclothes to prevent urinary leaking.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. Review the AUA Symptom Score and urologic test results from this patient’s clinic visit today. What do the results imply about the severity of this patient’s BPH and the patient’s response to treatment?

   Hint: See Tables 52-1 and Pathophysiology in PPP.

2. Tamsulosin is a modified release formulation. What are the clinical advantages of this formulation over the immediate release formulation?

   Hint: See Treatment in PPP.

3. This patient is taking tamsulosin 0.8 mg daily. Is this dose justified in this patient? Explain your response.

   Hint: See Table 52-4 in PPP.

4. This patient’s prostate gland is 50 g despite a treatment course of finasteride. Has the patient had an adequate clinical trial of finasteride?

   Hint: See Treatment in PPP.

5. The patient’s physician prescribes mirabegron 25 mg daily. Explain the rationale for using mirabegron in this patient. Explain how mirabegron may worsen blood pressure control in this patient.

   Hint: See Treatment in PPP.

6. Would sildenafil be expected to help relieve LUTS?

   Hint: See Treatment in PPP.

FOLLOW-UP

Discuss the indications for, and advantages and disadvantages of combination drug therapy for BPH

Hint: See Treatment in PPP.

CASE SUMMARY

Global Perspective

When symptoms are moderate to severe, drug therapy is indicated. α - Adrenergic antagonists quickly relieve LUTS, but do not prevent disease progression. 5α-reductase inhibitors delay symptom progression and reduce the incidence of BPH-related complications in patients with prostates of at least 30 to 40 g but may not reduce voiding symptoms for 3 to 6 months. However, BPH may be progressive in some patients. Additional drug therapy may be needed for worsening LUTS. Furthermore, if the patient develops complications of BPH, including recurrent urinary tract infection, hematuria, or renal impairment, then surgery is the treatment of choice.

Key References