BackTable / Urology / Podcast / Episode #5
Contemporary Medical Management of BPH
with Dr. Claus Roehrborn and Dr. Aditya Bagrodia
In Part I, Dr. Aditya Bagrodia talks with Dr. Claus Roehrborn of UT Southwestern Medical Center about the medical management of benign prostatic hyperplasia (BPH).
BackTable, LLC (Producer). (2021, April 22). Ep. 5 – Contemporary Medical Management of BPH [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Claus Roehrborn
Dr. Claus Roehrborn is a urologist with UT Southwestern in Dallas, Texas.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
In this episode of BackTable Urology, Dr. Claus Roehrborn, chairman and professor of UT Southwestern Urology department, joins our host Dr. Aditya Bagrodia to discuss the clinical evaluation and medical management of benign prostate hyperplasia (BPH).
Dr. Roehrborn begins by categorizing lower urinary tract symptoms (LUTS), which are suggestive of BPH, into 2 groups: storage vs. voiding symptoms. He emphasizes the importance of evaluating the patients via the International Prostate Symptom Score (IPSS), asking about the patients’ quality of life, and considering absolute indications for intervention (retention, gross hematuria, recurrent UTI) before formulating a treatment plan for BPH.
Additionally, Dr. Roehrborn highlights two important pre-treatment tests: the flow rate test, which judges the stream intensity, and the post-void residual (PVR) urine test, which measures residual volume. Dr. Roehrborn encourages urologists to use the voided volume and residual volume to calculate the voiding efficiency, a powerful tool to drive treatment options. Finally, he advocates for the Prostate Screening Assessment (PSA) as an effective indirect measure of prostate size, since urologists should know the size and shape of the prostate before embarking on treatment.
In the last part of the episode, Dr. Roehrborn discusses the 5 classes of BPH medication (alpha adrenergic receptor blocker, 5-alpha-reductase inhibitor, anticholinergics, beta-3-adrenergic agonists, and phosphodiesterase 5 inhibitors), their side effects, and their efficacies based on each BPH patient category. He notes that positive results are possible when combining 2 classes of medication and that urologists should always guide patients through increasing dosage and tapering medications during follow-up visits.
AUA Benign Prostate Hyperplasia Guidelines: https://www.auanet.org/guidelines/guidelines/benign-prostatic-hyperplasia-(bph)-guideline
EAU Lower Urinary Tract Sympton Guidelines: https://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/
AUA Microhematuria Guidelines: https://www.auanet.org/guidelines/guidelines/microhematuria
AUA Prostate Screening Assessment Guidelines: https://www.auanet.org/guidelines/guidelines/prostate-cancer-early-detection-guideline
That gets us to the last class, you mentioned that yourself, the PDE5 inhibitors, and for practical reasons, only Cialis five milligram is really approved for it as a daily dose, and that has to do with the half life. The other PDE5 inhibitors just don't have a sufficient half life to give a full day's worth of effect, so you would have to take it twice a day. But Cialis, five milligram is around for 24 hours, so you can give it once a day. And it is as effective as an alpha blocker. There was a pivotal randomized trial done in Europe showing that, and it just works as good as an alpha blocker on symptoms and also on the quality of life aspects of it.
The crucial difference is that you want to give that to patients who in that category have both. They have some erectile dysfunction and they have voiding dysfunction. And it makes really good sense to give those patients Cialis because it is just like an alpha blocker for the voiding symptoms, but it also does help for erectile dysfunction. So, globally speaking, you can take patients, categorize them, and allocate them for the best treatment. Alpha blocker alone, 5-ARI plus alpha blocker, anticholinergic or a beta-3 adrenergic agonist plus/minus an alpha blocker, And then the PDE5 inhibitors usually as a mono therapy. But if it's a big prostate, you can couple of them also was the 5-ARI. And those are your classes of medical therapies for your patients to send them out of the door with.
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