What is the medical management for prostatomegaly with concretions?

Medical Management of Prostatomegaly with Concretions

Alpha blockers are the first-line medical therapy for prostatomegaly with concretions, particularly in patients with moderate to severe lower urinary tract symptoms (LUTS) or acute urinary retention. 1, 2

First-Line Pharmacological Management

Alpha Blockers

• Alpha blockers provide rapid symptom improvement (within days to weeks) for moderate to severe LUTS associated with BPH 1, 2

• Options include:

  • Tamsulosin 0.4mg once daily
  • Alfuzosin 10mg once daily
  • Silodosin 8mg once daily
  • Doxazosin 4-8mg once daily
  • Terazosin 5-10mg once daily

• For acute urinary retention specifically:

  • Prescribe an alpha blocker prior to attempting catheter removal 1
  • Complete at least 3 days of alpha blocker therapy before attempting trial without catheter (TWOC) 1
  • Success rates for catheter removal with alpha blockers vs placebo: 60% vs 39% for alfuzosin; 47% vs 29% for tamsulosin 1

Selection Considerations

• Tamsulosin and alfuzosin have less tendency to cause hypotensive effects compared to non-selective alpha blockers 3
• Tamsulosin offers advantages including once-daily dosing, no need for dose titration, and minimal interference with antihypertensive therapy 3
• Sexual side effects differ between agents, with silodosin having higher rates of ejaculatory dysfunction 4

Second-Line and Combination Therapies

5-Alpha Reductase Inhibitors (5-ARIs)

• For patients with prostatic enlargement (>30cc on imaging, PSA >1.5ng/mL, or palpable enlargement on DRE) 1, 2
• Options:
  • Finasteride 5mg daily
  • Dutasteride 0.5mg daily
• Benefits:
  • Reduces risk of acute urinary retention by 57% 5
  • Reduces need for BPH-related surgery by 55% 5
  • Decreases prostate volume by approximately 18% over 4 years 5

Combination Therapy

• Alpha blocker + 5-ARI combination is more effective than monotherapy for men with enlarged prostates and moderate-to-severe symptoms 2
• FDA-approved combinations:
  • Finasteride + tamsulosin
  • Dutasteride + tamsulosin
• Note: Combination therapy increases side effect profile 2

Management Algorithm for Prostatomegaly with Concretions

1. For moderate-severe symptoms (IPSS ≥8) with prostatomegaly and concretions:

   • Start with alpha blocker (tamsulosin 0.4mg daily preferred for better side effect profile)
   • If prostate >30cc: Consider adding 5-ARI (finasteride 5mg daily)
   • Evaluate response after 3-6 months

2. For acute urinary retention with prostatomegaly and concretions:

   • Insert catheter
   • Start alpha blocker (tamsulosin 0.4mg daily)
   • Continue for at least 3 days before attempting catheter removal
   • Inform patient about 40-60% success rate and risk of recurrent retention 1
   • Consider adding 5-ARI for long-term management if prostate >30cc

3. For refractory cases:

   • Consider surgical intervention if patient has:
     • Failed medical therapy
     • Recurrent urinary retention
     • Recurrent UTIs
     • Renal insufficiency
     • Recurrent gross hematuria
     • Bladder stones 1

Monitoring and Follow-up

• Evaluate patients 3-6 months after initiating therapy 2
• Assess:
  • Symptom improvement (IPSS score)
  • Medication adherence
  • Side effects
  • Post-void residual volume
  • PSA levels (expect doubled value if on 5-ARI) 2

Important Considerations and Caveats

• Alpha blockers provide rapid symptom relief but don't alter disease progression 2
• 5-ARIs take 3-6 months for clinical effect but reduce long-term complications 2, 5
• Inform patients about potential sexual side effects of medications 2
• Patients who pass a successful trial without catheter after acute urinary retention remain at increased risk for recurrent retention 1
• Combination of PDE-5 inhibitors with alpha blockers is not recommended due to increased side effect risk 1

For patients with prostatomegaly and concretions who fail medical management, surgical options should be considered, particularly if they develop complications such as recurrent UTIs, bladder stones, or renal insufficiency 1.