Knee Fracture: Diagnosis, Classification and Treatment

Knee fracture or fractures of the knee joint can include the following

• fractures of the lower end of femur
• fractures of the upper end of tibia
• fractures of the patella

Here on this page we will know about fractures of the lower end of femur that are called Supracondylar and Intercondylar femur fractures.
The lower end of the femur bone is broad and forms two curved structures that are called condyles. The one located on the inner side is called medial condyle and the one on the outer side is called lateral condyle. In the front the condyles are united with each other. Behind they are separated by a space called the intercondylar notch.
The supracondylar area of the femur is the part that lies between the condyles and the shaft of the femur. Intercondylar area is the part between the two condyles.
In young adults these fractures result from high energy injuries such as road traffic accidents. In the elderly they occur following a minor fall with the knee joint flexed in weak osteoporotic bone.
Symptoms include the following

• Patient will give a history of a fall or accident.
• Severe pain and swelling will be present.
• Deformity is seen in the thigh or knee.
• Inability to lift the leg and inability to walk.
• The ankle and the toes can be moved freely unless there is a neuro-vascular injury along with the fracture.

In elderly people there may not be much pain and swelling. History of injury may also be vague. Inability to walk and lift the leg should alert us to the possibility of a fracture.
Diagnosis of the fracture can be easily made with x rays of the knee joint taken in two planes. At times it is difficult to understand the fracture pattern on x rays. In such conditions if is advisable to get a CT scan with three dimensional reconstruction of the fractured knee. This greatly helps in planning of definitive treatment.
These fractures are classified in three types based on the pattern of the fracture. They can be

• Extra-articular or supracondylar in which the fracture does not extend to the knee joint line.
• Partial-articular or condylar in which the fracture extends to the knee joint line but part of the condyles remain attached to the femur shaft.
• Complete-articular or intercondylar in which the fracture extends to the knee joint line but the condyles are completely separated from the femur shaft.

Treatment of knee fracture is decided by the classification of the fracture along with the degree of displacement, which can be either displaced or un-displaced.
All un-displaced knee fractures can be treated by a groin to toe plaster cast. This cast is applied for a period of 6 to 12 weeks depending on the age and general condition of the patient. Early removal of the cast followed by the application of knee brace is advisable. This allows movement of the knee while maintaining fracture alignment. When to remove the cast and apply the knee brace has to be decided by the treating doctor.
During cast treatment it is essential to repeat x rays every 10 to 15 days as these fractures can displace within the cast. Maintaining fracture alignment in a cast is more difficult in obese people.
All displaced fractures are treated surgically. Surgical fixation of the fracture can be done with either screws only, a plate and screws or a nail.

• Extra-articular or supracondylar fractures are usually treated with a nail.
• Partial-articular or condylar fractures are usually treated with screws only.
• Complete-articular or intercondylar fractures are usually treated with plate and screws.

Common complications seen with knee fracture include the following

• Loss of knee movement. This is seen more in partial-articular and complete-articular fractures, delay in surgery and after cast immobilization.
• Non-union or failure of the fracture to unite. This is seen more in the extra-articular or supracondylar fractures.
• Arthritis of the knee joint following fracture healing in a wrong position or due to damage of knee joint cartilage at the time of injury.
• Infection
• Deep-vein thrombosis

Frequently Asked Questions

How much time does it take for the fracture to heal?Most fractures heal enough within 8 to 12 weeks so as to allow walking.
How can loss of knee movement be prevented?
Loss of knee movement can be prevented by

• Stable and strong surgical fixation of the fracture allowing early postoperative mobilization of the knee joint.
• Meticulous handling of the skin and muscles around the knee during surgery so as to minimise scar tissue formation.

How long does it take to reach the activity and strength level as before the fracture?
Any fracture results in muscular weakness, and muscles take time to recover. For quick recovery stimulating the muscles in a organised and goal oriented way is essential.With out physiotherapy it can take 8 months to a year to reach the the pre-fracture level of muscle power and agility.
If you want to return quickly to the pre fracture level of activity following a knee fracture you need an intensive physiotherapy program.


This above is a CT scan of a young male showing a complete articular knee fracture. This fracture was sustained in a motor cycle accident. The patella bone was fractured in multiple pieces and so had to be removed. The remaining femur pieces were stabilized with a locking plate and screws as shown in the x ray below.


The x ray shown below is of a 70 year old male with severe osteoporosis and a extra-articular fracture that he sustained when he slipped on the way to the bathroom. When I first examined him there wasn't much swelling and he was not complaining of much pain. His inability to lift the limb alerted me to the possibility of a fracture. He was treated by the insertion of a titanium nail. A knee brace was used in the post-operative period.

Da Vinci Surgical System

Introduction:
With already over 210 devices in use throughout the United States, Europe, and Japan, Intuitive Surgical is the leading company in the field of digital surgery with its da Vinci? Surgical System. Approved in July 2000 to perform advanced surgical techniques such as cutting and suturing, this system is the first operative surgical robotic system to be cleared by the FDA, giving it a first-mover advantage over its competitors. Though Intuitive Surgical has had to overcome many obstacles in order to dominate the digital surgery field, it is now a multimillion-dollar business that continues to grow¹.
System Overview
^*
Making a one-centimeter keyhole incision to perform the operation, the surgeon is able to engage in minimally invasive surgery through this system. According to Ben Gong, Intuitive Surgical's vice president of finance, da Vinci reduces the average 2-3% infection probability to nearly zero². There are four main components to da Vinci: the surgeon console, patient-side cart, EndoWrist Instruments, and Insite Vision System with high resolution 3D Endoscope and Image Processing Equipment.
1. Surgeon Console
The surgeon is situated at this console several feet away from the patient operating table. The surgeon has his head tilted forward and his hands inside the system’s master interface. The surgeon sits viewing a magnified three- dimensional image of the surgical field with a real-time progression of the instruments as he operates. The instrument controls enable the surgeon to move within a one cubic foot area of workspace.

2. Patient-side Cart
This component of the system contains the robotic arms that directly contact the patient. It consists of two or three instrument arms and one endoscope arm. The feedback as of today is limited to sensing tool-on-tool collision, so the surgeon needs to rely almost solely on the visual field when suturing or contacting soft tissue. As of 2003, Intuitive launched a fourth arm, costing $175,000, as a part of a new system installation or as an upgrade to an existing unit². It provides the advantages of being able to manipulate another instrument for complex procedures and removes the need for one operating room nurse³.

3. Detachable Instruments
(Endowrist® Instruments and Intuitive® Masters)
The Endowrist detachable instruments allow the robotic arms to maneuver in ways that simulate fine human movements. Each instrument has its own function from suturing to clamping, and is switched from one to the other using quick-release levers on each robotic arm. The device memorizes the position of the robotic arm before the instrument is replaced so that the second one can be reset to the exact same position as the first. The instruments’ abilities to rotate in full circles provide an advantage over non-robotic arms. The seven degrees of freedom (meaning the number of independent movements the robot can perform) offers considerable choice in rotation and pivoting⁴. Moreover, the surgeon is also able to control the amount of force applied, which varies from a fraction of an ounce to several pounds. The Intuitive Masters technology also has the ability to filter out hand tremors and scale movements. As a result, the surgeon’s large hand movements can be translated into smaller ones by the robotic device⁵. Carbon dioxide is usually pumped into the body cavity to make more room for the robotic arms to maneuver.



4. 3-D Vision System
(Insite® Vision and Navigator Camera Control)
The camera unit or endoscope arm provides enhanced three-dimensional images. This high-resolution real-time magnification showing the inside the patient allows the surgeon to have a considerable advantage over regular surgery. The system provides over a thousand frames of the instrument position per second and filters each image through a video processor that eliminates background noise. The endoscope is programmed to regulate the temperature of the endoscope tip automatically to prevent fogging during the operation³. Unlike The Navigator Control, it also enables the surgeon to quickly switch views through the use of a simple foot pedal.

Competitors: Just a few years ago, Intuitive Surgical was in the midst of a fierce legal battle with its competitor, Computer Motion. The series of events was offset by a lawsuit filed by Computer Motion for nine patent infringements. Intuitive Surgical then filed three lawsuits of its own and made a final blow by teaming with IBM to sue its competitor for infringing on its voice-recognition technology. Computer Motion lost the case for this integral component of all its devices including Zeus, its version of da Vinci. It faced a major problem since it would have to stop selling in the event that it could not receive a proper license from its competitor. On March 7, 2003, Intuitive Surgical merged with its main competitor⁶, ending a four-year legal power struggle that detracted from product advancement and funds⁷. Intuitive Surgical paid $150 million for Computer Motions and laid off around 90% of its employees following the merger². Intuitive now owns and will market Computer Motion's products (Zeus Surgical System, Hermes Control Center, Aesop Robotic Endoscope Positioner, and Socrates Telecollaboration System)⁸.
Market Information of the Robot Surgical Systems

Equipment	Costs	Company	Equipment Descriptions
da Vinci Surgical System	$1 million	Intuitive Surgical	Robot-assistant, with arms to connect surgical instruments
Zeus Robot Surgical System	$975,000	Computer Motion*	Robot-assistant, with arms to connect surgical instruments
Aesop 3000	$80,000	Computer Motion*	Voice-controlled endoscope-positioning robot
Hermes Control Center	Request price quota	Computer Motion*	Centralized system used to network an intelligent OR
Socrates Robotic Telecollaboration System	Request price quota	Computer Motion*	Allows shared control of Aesop 3000 from different locations

*Former Computer Motion systems that are now owned by Intuitive Surgical. Sources: Table 1 from Journal of Healthcare Management 46:4 July/August 2003 Advantages and Disadvantages:
The da Vinci Surgical System reduces hospital stays by about half, reducing hospital cost by about 33%⁹. These fewer days in the intensive care unit are a result of less pain and quicker recovery. Though the size of the device is still not small enough for heart procedures in children, the minimally invasive nature of da Vinci does not leave a large surgical scar and still has some limited applications in children for the time being. Moreover, according to Intuitive Surgical, only 80,000 out of 230,000 new cases of prostate cancer undergo surgery because of the high risk invasive surgery carries, implying that more people may undergo surgery with this evolving technology². The main drawbacks to this technology are the steep learning curve and high cost of the device. Though Intuitive Surgical does provide a training program, it took surgeons about 12-18 patients before they felt comfortable performing the procedure¹⁰. One of the greatest challenges facing surgeons who were training on this device was that they felt hindered by the loss of tactile, or haptic, sensation (ability to “feel” the tissue). The large floor-mounted patient-side cart limits the assistant surgeon’s access to the patient. However, there are also many who are unable to access the da Vinci based on the steep price. In a paper published by The American Journal of Surgery, 75% of surgeons claimed that they felt financially limited by any system that cost more than $500,000¹¹. As of now, surgery with the da Vinci Surgical System takes 40-50 minutes longer, but the FDA considered this a learning curve variable and expects time to improve with more use of the system¹².
Estimate of Initial Investment and Cost Savings per Heart-Valve Surgery for da Vinci® Market Price

Maintenance/year Physician Training	$1 million $100,000 $250,000
Cost of one inpatient hospital day	$2,000
Reduced inpatient hospital days for heart procedures	4.5 days
Cost saving per heart procedure due to reduced hospital stay	$9,000 per heart valve
Extra procedure cost	$2000 more per operation
Surgical assistance	$175,000 for fourth arm (Compared to $80,610 per year for extra OR nurse)

Sources: Table 2 from Journal of Healthcare Management 46:4 July/August 2003 Salary Survey 2004. Nursing Management 35: 7 July 2004 Pages 28-32 American Heart Association's Scientific Sessions 2002 Costs Though Intuitive Surgical has faced some setbacks during its legal battles with Computer Motion, it has recovered quickly and has been growing at an unprecedented rate since the merger. The total sale for the first year of 2004 was $138.8 million (a 51% increase from the previous year) with a total of $60 million in revenue. This includes recurring revenue from instruments, disposable accessories, and services, which have also increased accordingly in response to the larger number of systems installed and greater usage in hospitals. In 2004 alone, 76 da Vinci Systems, each costing about $1.5 million, were sold¹³.
Reimbursement:
Medical reimbursement by insurance companies is specific to each respective company. However, Medicare reimbursement is available for laparoscopic and thoracoscopic procedures since the da Vinci Surgical System has been FDA approved for commercial distribution in the United States¹⁴.
FDA Approval:


http://www.intuitivesurgical.com/news_room/fda_clear.html

Date	Procedure
April 26, 2005	Gynecological Laparoscopic Procedures
January 30, 2003	Totally Endoscopic Atrial Septal Defect (ASD)
November 13, 2002	Mitral valve repair surgery
November 12, 2002	Thoracoscopically-Assisted Cardiotomy Procedures, K022574
July 11, 2000	General Laparoscopic Surgery (gallbladder, gastroesophageal reflux and gynecologic surgery), K990144
March 5, 2001	Thoracoscopic Surgery (IMA Harvesting for Coronary Artery Bypass and Lung surgery), K002489
May 30, 2001	Laparoscopic Radical Prostatectomy, K011002
July 31, 1997	Surgical Assistance, K965001

Fail Safe Mechanisms Safety concerns remain the center of focus for Intuitive Surgical. To start the procedure, the surgeon’s head must be placed in the viewer. Otherwise, the system will lock and remain motionless until it detects the presence of the surgeon’s head once again. During the procedure, a zero-point movement system prevents the robotic arms from pivoting above or at the one-inch entry incision, which could otherwise be unintentionally torn. Included in the power source is a backup battery that allows the system to run for twenty minutes, giving the hospital enough time to reestablish power. Each instrument contains a chip that prevents the use of any instrument other than those made by Intuitive Surgical. These chips also store information about each instrument for more precise control and keep track of instrument usage to determine when it must be replaced.

Future Outlook
Besides the cost, the da Vinci Surgical System still has many obstacles that it must overcome before it can be fully integrated into the existing healthcare system. From the lack of tactile feedback to the large size, the current da Vinci Surgical System is merely a rough preview of what is to come. Spending around $16.2 million in 2003 alone, Intuitive Surgical has a first-mover advantage over its competitors and continues to lead on as it receives more and more FDA approvals. More improvements in size, tactile sensation, cost, and telesurgery are expected for the future

Atrial fibrillation

Introduction

Atrial fibrillation is a condition in which there is disorganized atrial activity resulting in loss of effective atrial contraction. The atria beat between 350 and 600 times per minute. These rapid, irregular impulses pass through the AV node of the heart to the ventricles and result in a rapid and "irregularly irregular" ventricular response. There are paroxysmal and persistent forms.

Epidemiology

Incidence and prevalence

AF is the most common sustained arrhythmia.
Approximately 2.2 million individuals in the United States and 4.5 million individuals in the European Union have atrial fibrillation.[1,2]

Gender

Men are more likely than women to develop AF, but women diagnosed with it carry a longer-term risk of premature death.

Age

The incidence of atrial fibrillation increases with age. The prevalence in individuals over the age of 80 is about 8%.[3] In developed countries, the number of patients with atrial fibrillation is likely to increase during the next 50 years, due to the growing proportion of elderly individuals.[4]

Race

Blacks have half the age adjusted incidence when compared to Caucasians.

Causes of AF

1. Coronary heart disease
2. Congestive heart failure
3. Pericarditis
4. Myocarditis
5. Rheumatic heart disease
6. Hypoxia
7. Hypertrophic cardiomyopathy
8. Hypertensive cardiomyopathy
9. Dilated cardiomyopathy
10. Pulmonary embolism
11. Alcohol
12. Lone atrial fibrillation
13. Thyrotoxicosis
14. Theophylline
15. Blunt trauma
16. Sick sinus syndrome
17. Sympathomimetic toxicity
18. Post-CABG surgery

Risk factors

Risk factors for development of AF include:

1. Those who have had coronary heart disease, heart attack or heart failure.
2. It's also found in people with heart valve disease, an inflamed heart muscle or lining (endocarditis) or
3. Recent heart surgery
4. People with atherosclerosis and angina
5. Congenital heart defects
6. People with chronic lung disease, emphysema and asthma
7. Thyroid disorders
8. Diabetes
9. High blood pressure
10. Excessive consumption of alcohol, cigarette or stimulant drugs, including caffeine.

Pathogenesis

Atrial fibrillation is caused by multiple re-entrant circuits or "wavelets" of activation sweeping around the atrial myocardium. These are often triggered by rapid firing foci. Conduction of atrial impulses to the ventricles is variable and unpredictable. Only a few of the impulses transmit through the atrioventricular node to produce an irregular ventricular response. Wavelength is critical in the pathogenesis of AF. Increased wavelength may prevent or end AF. This can be produced by antiarrhythmic drugs.

• Paroxysmal AF is characterized by brief episodes of the arrhythmia, which can resolve by themselves.
• In persistent AF, the episodes require some form of intervention to return the heart rhythm back to normal.
• For those with permanent AF, intervention (if successful at all) only restores normal heart rhythm for a brief time.

As the uncoordinated atrial depolarizations from various places within the atria in AF causes blood in the upper chambers of the heart not to be carried through in a regular manner, there is a tendency for blood clots to form in these chambers. These clots may then be swept into the ventricles and pumped into the lungs from the right side of the heart and into the general circulation from the left ventricle. Sometimes, clotted blood dislodges from the atria and results in a stroke.

Symptoms and signs

The symptoms of atrial fibrillation (AF) include palpitations, irregular heart beat, shortness of breath, chest discomfort, dizziness and syncopal attacks. Many patients experience feelings of weakness, exercise intolerance, caused by the heart�s diminished pumping ability. The awareness of a rapid and/or irregular heart beat also may lead to anxiety. Systemic embolization may result as well as precipitation or intensification of heart failure.
Patients who have otherwise healthy hearts may be better able to tolerate AF. People with underlying heart disease are generally less able to tolerate AF without complication. Once AF becomes symptomatic, it becomes more serious as it indicates that the heart is failing to pump adequate amounts of blood to the body.
The ventricular rate depends on the degree of atrioventricular block, but when 1:1 conduction occurs a rapid ventricular response may result. Increasing the degree of block with carotid sinus massage or adenosine may aid the diagnosis.

Complications

• Stroke: The relative risk for the development of stroke can be determined by assessing the patient's CHADS2 score.
• Heart failure: Heart failure and pulmonary edema can be precipitated or aggravated by AF.
• Cardiac ischemia: Tachy-arrhythmia can precipitate ischemic heart disease.

Diagnosis

Atrial fibrillation can be strongly suspected simply by feeling the pulse, but a complete diagnosis calls for full medical investigation.

EKG

One of the most important tests is the electrocardiograph (EKG), which can also give evidence of any previous heart disease that may have been the cause of the condition. If the AF is intermittent, it may be necessary for the patient to wear a Holter monitor for an extended period of time in order to catch one or more episodes of AF. Often the EKG and Holter are used in conjunction with a chest x-ray and echocardiogram, which shows the heart walls as they are beating. EKG features in AF include:

• P waves absent; oscillating baseline f (fibrillation) waves
• Atrial rate 350-600 beats/min
• Irregular ventricular rhythm
• Ventricular rate 100-180 beats/min

Fast atrial fibrillation may be difficult to distinguish from other tachycardias. The RR interval remains irregular, however, and the overall rate often fluctuates. Mapping R waves against a piece of paper or with calipers usually confirms the diagnosis.

Imaging

A chest X-ray in a young patient may suggest the presence of congenital heart disease. In an older patient it can give information on the size of the heart and whether heart failure is present. The echocardiogram is useful in ruling out thrombus formation as well as determining the diameter of the left atrium (> 4.5 cm).

Blood tests

Routine blood tests can also be useful in the diagnosis. They may show anemia, which may be complicating the situation, impaired kidney function, or thyroid gland overactivity (thyrotoxicosis).

Treatment

Left untreated, the overactive heart muscle can weaken and stretch out. This makes it harder for the atria to contract properly, so blood backs up even more. This problem not only increases the risk of stroke, but it can also lead to congestive heart failure. Treating AF correctly is the best way to reduce stroke risk. Therapy is indicated in patients with persistent, permanent or recurrent paroxysmal AF. The goals of treatment plans for AF are:

• Prevent blood clots from forming
• Heart rate control within a relatively normal range
• Restore a normal heart rhythm, if symptomatic

1. Medicine to prevent clots

To lower the risk of stroke either aspirin or Warfarin are generally prescribed. Aspirin has an antiplatelet effect and is less likely to cause abnormal bleeding, but Warfarin seems to be more effective at preventing clot-caused strokes. Regular INR tests are carried out to monitor the dose of Warfarin. INR should usually test between 2.0 and 3.0.
The choice of giving a patient Warfarin or aspirin depends on the patient's risk factors for development of thromboembolic disease. This can be determined by assessing a patient's CHADS2 score.[5]

• CHF (1 point)
• Hypertension (1 point)
• Age 75 (1 point)
• Diabetes (1 point)
• Second stroke (2 points)

A patient with a low score (0) can receive aspirin 325 mg daily for prophylaxis against coagulation. Those with an intermediate score (1-2) can receive either aspirin or Warfarin depending on the patient's preference. Those with a high CHADS2 score (3 or more) should receive Warfarin prophylaxis to maintain an INR of 2.0-3.0, unless contraindicated (e.g., history of falls, clinically significant GI bleeding, inability to obtain regular INR screening).

2. Rate control

• Beta-blockers (like metoprolol, carvedilol or propanolol) and calcium-channel blockers (like verapamil or diltiazem), which slow the heart rate;
• Digoxin, which slows the heart rate through the AV node, therefore decreasing the rate at which the electrical impulses conduct from the atria to the ventricles.
• In cases who are refractory to the above measures or in those with heart failure or pre-exitation syndrome, use amiodarone, consider cardiac consultation,

3. Rhythm control (cardioversion)

Cardioversion changes an abnormal heart rate back to a normal one. Cardioversion can be done through medication or through electricity.
Based on the AFFIRM, RACE and STAF trials rate control with anticoagulation is the preferred treatment. Rhythm control (cardioversion) in asymptomatic patients does not appear to affect survival. Electrical or chemical cardioversion may be required in symptomatic cases or in emergency situations such as those with cardiovascular instability and heart failure.

• Chemical cardioversion

Medicines include amiodarone, dofetilide, disopyramide, flecainide and procainamide.

• Electrical cardioversion

Electrical cardioversion is typically used to treat cases of persistent or permanent AF, and it is often used with medication.
There are two types of electrical cardioversion: external and internal. For external cardioversion, two external paddles are placed on the patient�s chest or on the chest and back. A high-energy electrical shock is sent through the patches, through the body to the heart. The energy shocks the heart out of AF and back into normal rhythm.
Internal cardioversion uses a similar approach, but instead of using paddles on the outside of the body, a catheter is inserted through a vein to the heart. The electrical energy is delivered through the catheter to the inside of the heart to stop the AF. Internal cardioversion has met with high success and provides an alternative to external cardioversion.

4. Ablation

Cardiac ablation is a medical procedure performed to prevent abnormal electrical impulses from ever beginning in the first place. In an ablation procedure, the electrophysiologist first does mapping, which means the precise area in the heart at which the abnormal signals start are pin-pointed. The electrophysiologist then eliminates the small area of tissue that is causing the arrhythmia.
There is also a procedure called AV nodal ablation. This involves ablating the AV node, keeping the abnormal impulses from traveling to the heart�s lower chambers. A pacemaker is used to regulate the heartbeat after this therapy.

5. AF Suppression

AF Suppression is designed to suppress atrial fibrillation (AF). An implanted pacemaker stimulates the heart in a way that preempts any irregular rhythms.
A clinical study has found that a software-based AF Suppression algorithm can suppress symptomatic paroxysmal and persistent AF better than standard pacing. The AF Suppression algorithm is available in certain ICDs and pacemakers manufactured by St. Jude Medical.

Prognosis and survival

Prognosis is related to the underlying cause; it is excellent when due to idiopathic atrial fibrillation and relatively poor when due to ischemic cardiomyopathy. Healthy life style, regular checks on blood pressure and treatment for raised blood pressure can reduce the chances of developing the heart problems that cause atrial fibrillation.

Some study results

Among people with atrial fibrillation who not are taking the anticoagulant drug Warfarin, women are more likely to form dangerous blood clots than men, according to a study.
Men who explode with anger or expect the worst from people are more likely to develop an irregular heart rhythm called atrial fibrillation, according to another study report.

Aortic valve stenosis

Introduction

The aortic valve is a flap-like opening located between the left side of the heart and the aorta. The aorta is the main artery carrying blood from the heart. Blood is pumped by the left ventricle across the aortic valve into the aorta and the arteries of the body. Aortic stenosis causes restricted systolic opening of the valve leaflets, with a mean transvalvular pressure gradient of at least 5-10 mmHg. When the degree of narrowing becomes significant enough to impede the flow of blood from the left ventricle to the arteries, heart problems develop.
In the Euro Heart Survey on Valvular Heart Disease, aortic valve stenosis was the most common valve abnormality. Aortic valve sclerosis is commonly defined as a focal or diffuse thickening of the aortic cusps with calcific nodules generally at the base of leaflets and transvalvular velocity at Doppler still in the normal range (Vmax <2 m/s).

Epidemiology

Prevalence

Rheumatic valve disease has declined dramatically in the United States during the past 50 years, and isolated rheumatic aortic valve is unusual in any event. With our aging population, calcific aortic stenosis accounts for the vast majority of aortic valve disease. In the elderly, mild thickening and/or calcification of a trileaflet aortic valve without restricted leaflet motion (ie, aortic sclerosis) affects about 25% of the population > 65 years of age. Calcific aortic stenosis, however, affects approximately 2% to 3% of those > 75 years. Thus not all patients with aortic sclerosis will go on to develop obstructive aortic valve disease.

Incidence

The approximate overall incidence of an anatomic bicuspid aortic valve is 1% to 2% of the population. Of these individuals, most will go on to present with aortic stenosis, while a minority will develop a regurgitant lesion. Particularly, the aortic valve sclerosis (aortic valve thickening and calcification without pressure gradient) seem to affect about one fourth of adults over 65 years of age, while the aortic valve stenosis is present in 2�9% of general population over 65 years of age; an increased prevalence of both sclerosis and stenosis with aging (48% and 4% in those over 85 years) is observed.
The relative frequency of the postinflammatory disease (i.e. post-rheumatic) decreased from 30% to 18% and the relative frequency of the bicuspid aortic valve changed from 37% to 33%; in contrast, the relative frequency of degenerative-calcific aortic stenosis (an "atherosclerotic" form of disease, see below) increased from 30% to 46%. These differences were striking in subjects older than 70 years.

Gender

Aortic stenosis due to bicuspid valves affects males three times more often than females, but late-life calcific disease of a trileaflet valve involves both sexes equally.

Age

Aortic stenosis can occur at any age (because the causes are different) but is usually asymptomatic until middle or old age. Until few years ago, aortic stenosis was considered a physiologic process related to aging without clinical relevance. However, aortic valve sclerosis is not observed in about 50% of people over 80 years old.

Causes and risk factors

A number of conditions contribute towards aortic stenosis. Three conditions that are known to cause aortic stenosis are:

Valvular causes

1. Calcification of a bicuspid valve

Bicuspid aortic valve is the most common cause of aortic stenosis in patients under age 65. Normal aortic valves have 3 thin leaflets called cusps. About 2% of people are born with aortic valves that have only 2 cusps (bicuspid valves). Although bicuspid valves usually do not impede blood flow when the patients are young, they do not open as widely as normal valves with 3 cusps. The turbulent blood flow causes excessive wear and tear leading to calcification, scarring, and reduced mobility of the valve leaflets over time. About 10% of bicuspid valves become significantly narrowed, resulting in the symptoms and heart problems of aortic stenosis.

2. Senile calcific aortic stenosis

The most common cause of aortic stenosis in patients 65 years and over is called "senile calcific aortic stenosis." With aging, protein collagen of the valve leaflets is destroyed, and calcium is deposited on the leaflets. Once valve leaflet mobility is reduced by calcification, turbulence across the valve increases, causing scarring, thickening, and stenosis of the valve. Why this aging process progresses to cause significant aortic stenosis in some patients but not in others is not known.

3. Rheumatic fever

Rheumatic fever rarely causes isolated aortic stenosis. Rheumatic fever is a condition resulting from untreated infection by group A streptococcal bacteria. Damage to valve leaflets from rheumatic fever causes increased turbulence across the valve and more damage. The narrowing from rheumatic fever occurs from the fusion of the commissures of the valve leaflets. Rheumatic aortic stenosis usually occurs with some degree of aortic regurgitation. Under normal circumstances, the aortic valve closes to prevent blood in the aorta from flowing back into the left ventricle. In aortic regurgitation, the diseased valve allows leakage of blood back into the left ventricle as the ventricular muscles relax after pumping. These patients also have some degree of rheumatic damage to the mitral valve.

Subvalvular causes

• Subvalvular aortic stenosis
• Hypertrophic obstructive cardiomyopathy

Pathogenesis

Valvular aortic stenosis results in chronic left ventricular pressure overloading. At any stage of life, however, the natural history of aortic stenosis largely reflects the functional integrity of the mitral valve. As long as adequate mitral valve function is maintained, the pulmonary bed is protected from the systolic pressure overloading imposed by aortic stenosis. In contrast to mitral valve disease where the pulmonary circuit is directly involved, compensatory concentric left ventricular hypertrophy allows the pressure overloaded ventricle to maintain stroke volume with modest increases in diastolic pressure, and patients can remain asymptomatic for many years.Eventually, left ventricular hypertrophy results in either diastolic dysfunction with the onset of congestive symptoms or myocardial oxygen needs in excess of supply with the onset of angina.

Symptoms

Most patients with calcific aortic stenosis report knowing of a cardiac murmur for many years. Common symptoms of aortic stenosis include: coughing at night; fainting, especially with physical activity; fatigue; shortness of breath that worsens at night or with exertion; angina; and, visual impairments. Some patients may also experience exertional syncope, probably reflecting the inability to increase cardiac output and maintain blood pressure in response to vasodilation. Vasodepressor syncope, however, may be an operative mechanism in a portion of these syncopal episodes.

Signs

On physical examination, the harsh systolic diamond shaped (crescendo-decrescendo) murmur of aortic stenosis, loudest at the base of the heart and radiating to the carotids, is often, but not always, prominent. Low output states, obesity, or chronic lung disease may mask the findings. The murmur may radiate toward the cardiac apex, in which case the harsh component is lost; this finding may be mistaken for a second murmur. Other hallmarks of significant aortic valve stenosis include a single (pulmonic) component of the second heart sound and a sustained left ventricular apical impulse with a fourth heart sound. The slowly rising, low volume carotid arterial pulses of severe aortic stenosis may be noted in younger patients, but changes in arterial compliance often mask these findings in the elderly.

Assessment

Patients with typical findings of aortic stenosis should have a detailed history-taking session with inquiry into habitual activity levels and any changes in exercise tolerance. The onset of any of the classic symptoms of left ventricular outflow obstruction, namely angina, syncope, or heart failure, in a patient with valvular aortic stenosis indicates advanced valve disease and should be carefully and promptly evaluated. The severity of symptoms is not always related to the severity of the disease. In fact, people sometimes die suddenly from aortic stenosis without having had symptoms. Symptoms usually occur when the aortic valve area narrows to less than 1 square centimeter. Critical aortic stenosis is present when the valve area is less than 0.7 square centimeters.

Diagnosis

The electrocardiogram often shows changes of left ventricular hypertrophy. In rare instances, electrical conduction abnormality can also been seen.
The chest X-ray is seldom helpful, although occasionally heavy calcification of the valve or post-stenotic ascending aortic dilation may be seen.
With its widespread availability, two-dimensional and Doppler echocardiography has become the study of choice in the evaluation of patients with suspected valvular disease. Echocardiography allows assessment of the anatomy of the valve as well as chamber size and ventricular function. Doppler studies permit estimation of pressure gradients, as well as aortic valve area by employing the continuity equation.
With good quality echocardiography, cardiac catheterization is usually not required for diagnosis of patients with aortic stenosis. However, a cardiac catheterization is the gold standard in evaluating aortic stenosis. A pre-operative coronary angiography is generally performed in men over 40 years old and women over 50.

Treatment

Patients with (predominant) aortic stenosis fall into one of four categories of severity:

1. valve area > 1.2 cm2����������.mild
2. valve area 1.0 to 1.2 cm2��������.moderate
3. valve area 0.7 to 1.0 cm2��������.severe
4. valve area < 0.7 cm2����������.critical

1. Observation

Asymptomatic patients with mild to moderate aortic stenosis should have medical follow-up with regular inquiry as to changes in exercise tolerance or other symptoms. Serial echocardiographic examination should be based on an understanding of the natural history of the lesion, as outlined below. Patients should avoid strenuous activity, and particularly avoid post-prandial exertion. Infective endocarditis precautions following American Heart Association guidelines must be emphasized at each visit.

2. Antihypertensives

Hypertension occurs in about 20% to 30% of patients with mild to moderate aortic stenosis and should be managed with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers titrated slowly. Selected patients may be given modest doses of concomitant beta-blockers.
A supervised exercise tolerance test may provide helpful objective assessment in patients with echocardiographic evidence of moderate aortic stenosis who report atypical symptoms, who minimize complaints, or who are sedentary and therefore might not experience exercise intolerance. Functional limitation with inability to exercise to levels greater than 6 metabolic equivalents (METs) may, in some cases, be viewed as a "symptom." Stress testing is not advocated for patients with very severe left ventricular outflow obstruction.

2. Valve replacement

Symptomatic patients, ie, those with angina, syncope, dyspnea, with moderate, severe, or critical aortic stenosis should undergo valve replacement. Indications for aortic valve surgery include moderate aortic stenosis in patients requiring coronary bypass grafting and/or any other cardiac surgery, exercise-induced hypotension, and asymptomatic severe aortic stenosis with evidence of left ventricular dysfunction. Smoking cessation and diabetic control are mandatory after the replacement. Dental care should be completed with antibiotic prophylaxis before surgery.
The advantages and drawbacks of mechanical versus bioprosthetic valves should be discussed with the patient and his or her family. Often the choice of prosthesis is straightforward, but younger patients in particular may have special needs, which should be addressed Bioprosthetic valves offer the advantage of not requiring long-term oral anticoagulation, but have the drawback of relatively limited durability. In contrast, mechanical valves offer long-term durability, but require lifelong warfarin therapy. The generally accepted risk of serious bleeding with warfarin is on the order of 3% per year. Childbearing in women and vigorous sports activities in men are contra-indications to chronic oral anticoagulation with warfarin, and may figure importantly in the choice of valves. In general, bioprosthetic valves are preferred in patients over the age of 60 years and mechanical valves under the age of 50. Homograft aortic valve replacement with a cryopreserved cadaveric valve may offer specific advantages in patients with infective endocarditis or with disease of the aortic root. If significant narrowing of the coronary arteries is found, coronary artery bypass graft surgery (CABG) can be performed during aortic valve replacement surgery.

3. Balloon valvuloplasty

Balloon valvuloplasty is a technique that lowers the pressure across the valve by slightly enlarging the opening. This is usually done when someone is not stable enough for corrective surgery.
Current evidence indicates that calcific aortic stenosis progresses, on the average, at a rate of about 0.1 cm2 per year decline in valve area. To date, no medical therapy exists for the treatment of degenerative aortic stenosis. The possible impact of 'secondary prevention' measures, particularly lipid lowering with HMG-CoA reductase inhibitors (statins), on the progression of aortic stenosis is under investigation.

Follow up

Successful replacement of the valve restores normal blood flow. The long-term outcome is usually very good. Artificial valves wear out over a period of years. Their function is monitored, and the valves are replaced as necessary. A prosthetic heart valve commits a patient to continued infective endocarditis prophylaxis, regular cardiac follow-up, and often to continued medical therapy, including anticoagulation with warfarin for those with mechanical prostheses. Re-operation may be required for malfunction of the prosthetic valve. In addition, a small but not insignificant subset of patients may require implantation of a permanent pacemaker after valve surgery.

Prognosis and survival

Serious long-term effects of aortic stenosis without timely treatment include:

• congestive heart failure
• coronary heart disease
• enlargement of the left ventricle
• pulmonary edema
• sudden death (occurs in less than 1%)

With surgery, the patient can expect to live a normal life with necessary precautions as explained above.

Aortic aneurysm

 

 

Introduction

An aortic aneurysm is an abnormal bulge in the wall of the aorta. Enlargement of the aorta may be only mild in degree and termed "ectasia." In general, if the diameter of the aneurysm is more than 1.5 times the size of the normal aorta, it is called an aneurysm.
Although an aneurysm can develop anywhere along the aorta, abdominal aneurysms are more common than thoracic ones. An aortic aneurysm is serious because - depending on its size - it may rupture, causing life-threatening internal bleeding. The risk of an aneurysm rupturing increases as the aneurysm gets larger. The risk of rupture also depends on the location of the aneurysm. When detected in time, an aortic aneurysm can usually be repaired with surgery.

Epidemiology

Incidence

• Ruptured aortic aneurysm is the 13th leading cause of death in the US.
• More than 15,000 Americans die each year due to ruptured aneurysms, many of them needlessly.
• The number of aneurysms in the United States is increasing as the population increases.
• Many people don't even make it to the hospital, and those who do often die of complications.

Gender

Aneurysm is 5 times more common in men than in women.

Age

Clinically important aneurysms over 4 cm in diameter are present in about 1 percent of men between the ages of 55 and 64; the prevalence increases by 2 to 4 percent per decade thereafter.

Race and ethnicity

The disease is predominant in men of the white race. In black men, black and white women the incidence of aortic artery aneurysm (AAA) is identical.

Morbidity

38 to 50 percent of the AAA patients suffer from hypertension, 33 to 60% from coronary artery disease, 28% from cerebrovascular diseases and 25% from peripheral occlusive disease.

Causes and risk factors

• Age over 55 years (Risk increases with age)
• A family history of AAA is particularly concerning
• Smoking
• High blood pressure

Pathogenesis

Most aneurysms are caused by a breakdown in the proteins that provide the structural strength to the wall of the aorta. These proteins, called collagen and elastin can gradually deteriorate with age, but inflammation that is associated with atherosclerosis can accelerate this process even in younger people. There are also naturally occurring enzymes that cause the breakdown of collagen and elastin. An excess of these enzymes or other conditions that activate these enzymes may also contribute to the formation of an aneurysm, or its sudden growth. In rare cases an aneurysm may be caused by infection (mycotic aneurysms). There is still much to be learned about the cause of aneurysms and their growth, but fortunately we have successful, permanent treatments for AAA when they occur. Vascular surgeons have performed much of the basic research on aneurysm formation.

Types of Aortic Aneurysms

Aortic aneurysms are classified by shape, location along the aorta, and how they are formed.

True aneurysms and pseudoaneurysms

The wall of the aorta is made up of three layers: a thin inner layer of smooth cells called the endothelium, a muscular middle layer which has elastic fibers in it called the media, and a tough outer layer called the adventitia. When the walls of the aneurysm have all three layers, they are called true aneurysms. If the wall of the aneurysm has only the outer layer remaining, it is called a pseudoaneurysm. Pseudoaneurysms may occur as a result of trauma when the inner layers are torn apart.

Shape

• Fusiform aneurysms

Most fusiform aneurysms are true aneurysms. The weakness is often along an extended section of the aorta and involves the entire circumference of the aorta. The weakened portion appears as a generally symmetrical bulge.

• Saccular aneurysms

Occasionally an aneurysm may occur because of a localized weakness of the artery wall (saccular). Saccular aneurysms appear like a small blister or bleb on the side of the aorta and are asymmetrical. Typically they are pseudoaneurysms caused either by trauma (such as a car accident) or as the result of a penetrating aortic ulcer.

Location

• Thoracic aortic aneurysm (TAA)

A TAA is a diseased, weakened, and bulging section of the aorta in the chest. This condition, if not treated, could result in a rupture of the aorta, leading to life-threatening internal bleeding. The aneurysm may be caused by vascular disease, injury, or a genetic defect of the tissue. TAA is sometimes found in people with Marfan�s syndrome, which is characterized by many anomalies including elongated bones. It is also associated with Turner syndrome, which results from a missing X chromosome and is associated with dwarfism and arrested sexual development in addition to aortic aneurysm. TAA also can run in families independent of those two syndromes. Because it is difficult to diagnose victims often die young. People with TAA remain unaware of the risk they face because the slowly enlarging aorta does not cause any symptoms until it has reached a critical diameter. At that point, the aorta dissects or ruptures, both of which are life-threatening. Typically, the patient develops chest pain and usually goes to an emergency department to seek treatment.

• Abdominal aortic aneurysm (AAA)

More than 90% of abdominal aortic aneurysms originate below the renal arteries. The diameter is the most important predictor of aneurysm rupture with up to a 40% risk of rupture over 5 years for aneurysm > 5 cm. When they do rupture they tend to rupture leftward and posteriorly.

Symptoms and signs

Most aortic aneurysms have no symptoms. In fact, most are diagnosed on a chest X-ray or computerized tomography (CT) scan performed for evaluation of another condition, such as lung disease, or during routine exams. Symptoms may occur, however, due to the aneurysm pressing on nearby organs or tissue, or if the aneurysm leads to dissection. Symptoms of dissection include severe tearing pain in the chest or back, stroke, cold or numb extremities, or abdominal pain.

Screening

When aortic aneurysms are diagnosed early, treatment is safe and effective and the aneurysm is cured. AAA can be diagnosed by a simple ultrasound scan that can be performed in a few minutes without risk or discomfort.
Men between the ages of 65 and 75 who are or have been smokers should have a one-time ultrasound to screen for abdominal aortic aneurysm, according to a new recommendation from the U.S. Preventive Services Task Force. Nearly 70 percent of men in this age group have smoked and would benefit from routine screening to check for aneurysms.

Diagnosis

Most patients have no symptoms at the time an AAA is discovered. Aneurysms are often detected on tests that were performed for entirely different reasons. Abdominal aortic aneurysms may be diagnosed by a doctor during a physical exam, or sometimes patients notice a pulsating mass in their abdomen. The first hint of an aortic aneurysm may be an abnormal chest X-ray. Although AAA can be detected by physical examination, most are diagnosed today using an ultrasound scan or CAT scan, simple exams that are non-invasive and can be done as an outpatient. Magnetic resonance imaging (MRI) can also help. These exams also tell us about the size of the aneurysms � the key element to determine the need for treatment. Since major surgery was required in the past to repair an aortic aneurysm, that decision depended upon a comparison of the risk of rupture with risk of the surgery itself. Most doctors agree that for someone in good health, an AAA larger than 5 centimeters in diameter (about the size of a lemon) needs treatment. Smaller aneurysms may also need treatment if they cause symptoms (like back pain or abdominal pain), or tests show that the aneurysm has rapidly grown larger.

Treatment

1. Watch and wait

When detected in time, most ruptures can be prevented by repairing the aneurysms with an operation. Treatment for an aneurysm depends on its size and location and the general health of the person. If the aneurysm is small and without symptoms, a "watch-and-wait" approach may be suggested with regularly scheduled images of the aneurysm to check the size. However, if the aneurysm is large enough, or if the aneurysm is growing more than 1 centimeter per year, surgery may be the best option.
Women are more likely than men to die from aortic dissection according to one of the first studies of its kind reported. Aortic dissections may involve the ascending aorta alone, the descending thoracic and abdominal aorta alone, or the entire aorta. The risk of death depends on the extent of the dissection. It is highest for those aneurysms involving the ascending aorta. For that reason, most of these aneurysms are treated surgically as an emergency.

2. Medical treatment

Dissections of the descending thoracic aorta can often be treated with blood pressure control. The medical treatment of aortic dissection includes aggressive control of blood pressure and heart rate while the aorta heals. The risk of death with medical treatment of descending thoracic aortic dissection is about 10 percent. If surgery is required, however, the risk is higher at about 30 percent. Every effort is therefore made to treat these patients with medication.

3. Endovascular repair of AAA

Recent advances in catheter-based technologies have led to exciting new treatments for aortic aneurysms. Now, endovascular grafting technology allows surgeons to repair the AAA by delivering a graft through a small incision in the groin, rather than the traditional major open surgery. The endovascular method, approved by the FDA in 1999, allows the graft to be delivered via a catheter (tube) inserted in a groin artery. In the operating room, x-ray guidance is used for proper positioning of the graft. The graft is then expanded inside the aorta and held in place with metallic hooks rather than sutures. The hospital stay is usually only one or two days, and most patients can return to work or normal daily activities in about a week. Even patients with serious medical problems, once thought to be too sick, or too frail to have surgery for AAA, may have their aneurysm repaired using an endovascular graft. This can avoid the need for major open surgery and also eliminate the risk of fatal rupture if the AAA was not treated at all. It�s very important for patients to know that endovascular grafting may not be possible in every case. Endovascular grafts are specially manufactured and don�t �fit� for every case. Also, in many cases, standard surgery is still the best since we don�t have 50 years of experience with these newer procedures like we do with surgery. There may still be serious problems we haven�t anticipated.

4. Surgical resection

Surgery is usually required to repair an AAA, but modern, catheter-based technologies using endovascular grafts have made treatment less invasive in many cases. The combination of early diagnosis and modern treatment of aortic aneurysms can save countless lives lost due to aneurysm rupture each year.
Surgical treatment of AAA has been performed for almost 50 years and is a successful and durable procedure. In surgery the diseased part of the aorta is replaced with a Dacron or Teflon graft that is carefully matched to the normal aorta and is sewn in place by the surgeon. While ultimately curative, this operation requires a major abdominal incision and general anaesthesia, and the hospital stay averages 7-10 days for most patients. Even after uncomplicated surgery, it is often a month or two before patients can return to a full and normal life. Nevertheless, more than 90% of patients make a full recovery from surgery. After more than half a century of experience with these procedures we know that once patients have recovered, their aneurysms are permanently cured.

Follow up

Once the acute dissection has healed, adequate control of blood pressure may eliminate the need for surgery. Lifelong monitoring of diameter of the aorta is required because a previously dissected descending thoracic aorta may enlarge and rupture.

Prognosis and survival

Because the abdominal aorta is such a large blood vessel, a ruptured abdominal aneurysm is a life-threatening event. Fortunately, not all aneurysms rupture. Many grow very slowly and cause no symptoms or problems for many years. However, all have the potential to rupture and thus must be identified and treated or watched very carefully. The combination of earlier diagnosis with safer, simpler, and ever more successful treatments can prevent needless deaths due to ruptured abdominal aortic aneurysms. Timely suspicion and consultation with the family doctor and a simple ultrasound test can tell whether a person has aneurysm.
The length of the operation and the risks involved depends on the extent of the repair required, and on the patient's general health. Recovery time varies. Most people need at least a month or six weeks to recover from aneurysm surgery. The length of the hospital stay depends on the patient's condition and the operation performed, but it is typically a week.
Although endovascular surgery reduces recovery time to a few days, it still carries risk. And because the procedure is fairly new, long-term results are unknown. Complications can occur with this procedure, namely blood leaking from the graft, known as endoleak. For this reason, patients who have repair of their aortic aneurysms with stent-grafts are initially required to return for monitoring every six months.

Recent news and research

Cocaine users in their mid-40s are found to have more than four times the risk of coronary artery aneurysms as non-users as per the Journal of the American Heart Association. It is believed that cocaine predisposes to coronary artery aneurysms, and then the aneurysms themselves may predispose to heart attacks.
The Food and Drug Administration has approved a new device called GORE TAG Endoprosthesis System that is intended to prevent ruptures of descending thoracic aneurysms by making a new path for blood flow. It is the first endovascular grafting system approved to treat aneurysms of the thoracic aorta.

Benign Prostatic Hypertrophy Treatment & Management

Approach Considerations

Patients with mild symptoms (IPSS/AUA-SI score < 7) or moderate-to-severe symptoms (IPSS/AUA-SI score ≥8) of benign prostatic hyperplasia (BPH) who are not bothered by their symptoms and are not experiencing complications of BPH should be managed with a strategy of watchful waiting. In these situations, medical therapy is not likely to improve their symptoms and/or quality of life (QOL). In addition, the risks of treatment may outweigh any benefits. Patients managed expectantly with watchful waiting are usually re-examined annually.
Transurethral resection of the prostate (TURP) has long been accepted as the criterion standard for relieving bladder outlet obstruction (BOO) secondary to BPH. In current clinical practice, most patients with BPH do not present with obvious surgical indications; instead, they often have milder lower urinary tract symptoms (LUTS) and, therefore, are initially treated with medical therapy.
The era of medical therapy for BPH dawned in the mid 1970s with the use of nonselective alpha-blockers such as phenoxybenzamine. The medical therapeutic options for BPH have evolved significantly over the last 3 decades, giving rise to the receptor-specific alpha-blockers that comprise the first line of therapy.

Alpha-1–Receptor Blockade in Benign Prostatic Hyperplasia

A significant component of LUTS secondary to BPH is believed to be related to the smooth-muscle tension in the prostate stroma, urethra, and bladder neck. The smooth-muscle tension is mediated by the alpha-1-adrenergic receptors; therefore, alpha-adrenergic receptor–blocking agents should theoretically decrease resistance along the bladder neck, prostate, and urethra by relaxing the smooth muscle and allowing passage of urine.
BPH is predominantly a stromal proliferative process, and a significant component of prostatic enlargement results from smooth-muscle proliferation. The stromal-to-epithelial ratio is significantly greater in men with symptomatic BPH than in those with asymptomatic BPH.
The 3 subtypes of the alpha-1 receptor include 1a, 1b, and 1c. Of these, the alpha-1a receptor is most specifically concentrated in the bladder neck and prostate. Provided that the alpha-1a subtype is predominant in the prostate, bladder neck, and urethra, but not in other tissues, drugs that are selective for this receptor (ie, tamsulosin) may have a potential therapeutic advantage.
Tamsulosin is considered the most pharmacologically uroselective of the commercially available agents because of its highest relative affinity for the alpha-1a receptor subtype. In 2008, the US Food and Drug Administration (FDA) approved a new alpha-1a receptor selective blocker, silodosin (Rapaflo). It is indicated for treatment of the signs and symptoms of BPH.
The efficacy of the titratable alpha-blockers doxazosin and terazosin (Hytrin) is dose-dependent. Maximum tolerable doses have not been defined for any alpha-blocker; however, the higher the dose, the more likely the adverse events (orthostatic hypotension, dizziness, fatigue, ejaculatory disorder, nasal congestion). Despite the requirement for dose titration and blood pressure monitoring, these older, often less costly, alpha-blockers appear to be equally effective to tamsulosin and alfuzosin, and the 2010 AUA guidelines state that they remain reasonable choices for patients with moderate-to-severe LUTS due to BPH.^[2]
An approximately 4- to 6-point improvement is expected in IPSS/AUA-SI scores when alpha-blockers are used. Interestingly, alpha-blocker therapy has not been shown to reduce the overall long-term risk for acute urinary retention (AUR) or BPH-related surgery.^[7]
Hellstrom and Sikka reported in 2006 that the acute administration of tamsulosin effects ejaculatory function and ejaculate volume. Nearly 90% of study subjects experienced decreased ejaculate volume, and approximately 35% experienced anejaculation. In their study, subjects treated with alfuzosin or placebo did not experience anejaculation.^[8]

Alpha-adrenergic receptor blockers

The alpha-blocking agents administered in BPH studies can be subgrouped according to receptor subtype selectivity and the duration of serum elimination half-lives, as follows:

• Nonselective alpha-blockers - phenoxybenzamine
• Selective short-acting alpha-1 blockers - prazosin, alfuzosin, indoramin
• Selective long-acting alpha-1 blockers - terazosin, doxazosin, slow-release (SR) alfuzosin.
• Partially subtype (alpha-1a)–selective agents – tamsulosin, silodosin

Nonselective alpha-blockers

Phenoxybenzamine was the first alpha-blocker studied for BPH. It is nonselective, antagonizing both the alpha 1- and alpha 2-adrenergic receptors, which results in a higher incidence of adverse effects. Because of the availability of more alpha-1-receptor–specific agents, phenoxybenzamine is currently not often used for the treatment of BPH. The 2010 update to the AUA guideline for BPH retains the statement that insufficient data exist for a recommendation of phenoxybenzamine or of prazosin for treatment of LUTS secondary to BPH. This statement was originally published in the 2003 AUA BPH guidelines.^[2]

Phosphodiesterase-5 enzyme inhibitors

Statistically significant symptomatic improvements have been reported for patients with BPH receiving tadalafil. It has also been approved for the treatment of simultaneous BPH and erectile dysfunction (ED). Phosphdiesterase-5 (PDE5) inhibitors are known to mediate smooth muscle relaxation in the lower urinary tract.

Intraoperative floppy iris syndrome

Intraoperative floppy iris syndrome (IFIS) is characterized by miosis, iris billowing, and prolapse in patients undergoing cataract surgery who have taken or currently take alpha-1-blockers. It is particularly prevalent among patients taking tamsulosin. The 2010 AUA guideline recommends that clinicians ask patients about planned cataract surgery when offering alpha-blocker therapy for LUTS due to BPH. Alpha-blockers should not be initiated until cataract surgery is completed.^[2] Patients currently on alpha-blocker therapy must disclose this to their ophthalmologist prior to cataract surgery so that the appropriate preoperative and intraoperative precautions can be taken. Experienced ophthalmologists can thereby reduce the risk of complications from IFIS.^{[9, 2]}
In a review by Bell et al, exposure to tamsulosin within 14 days of cataract surgery was significantly associated with serious postoperative ophthalmic adverse events, specifically IFIS and its complications (ie, retinal detachment, lost lens or fragments, endophthalmitis). No significant associations were noted with exposure to other alpha-blocker medications or to previous exposure to tamsulosin or other alpha-blockers.^[10]

5-Alpha-Reductase Inhibitors in Benign Prostatic Hyperplasia

Hormonal medical management emerged from the discovery of a congenital form of pseudohermaphroditism secondary to DHT deficiency (due to a lack of 5-alpha-reductase activity). This deficiency produced a hypoplastic prostate. The two types of 5-alpha-reductase include type 1 (predominantly located in extraprostatic tissues, such as skin and liver) and type 2 (predominant prostatic reductase).
Inhibition of 5-alpha-reductase type 2 blocks the conversion of testosterone to DHT, resulting in lower intraprostatic levels of DHT. This leads to inhibition of prostatic growth, apoptosis, and involution. The exact role of 5-alpha-reductase type 1 in normal and abnormal prostatic development is undefined. 5-Alpha-reductase inhibitors improve LUTS by decreasing prostate volumes; thus, patients with larger prostates may achieve a greater benefit. Further, maximal reduction in prostate volume requires 6 months of therapy.

5-Alpha reductase inhibitors

Finasteride (Proscar), a 4-aza-steroid, has demonstrated 5-alpha type II–blocking activity, resulting in the inhibition of DHT-receptor complex formation. This effect causes a profound decrease in the concentration of DHT intraprostatically, resulting in a consistent decrease in prostate size. One third of men treated with this agent exhibit improvements in urine flow and symptoms.
Dutasteride (Avodart) has an affinity for both type 1 and type 2 5-alpha-reductase receptors. The significance of blockage of type 1 receptors is currently unknown.
Both finasteride and dutasteride actively reduce DHT levels by more than 80%, improve symptoms, reduce the incidence of urinary retention, and decrease the likelihood of surgery for BPH. Adverse effects are primarily sexual in nature (decreased libido, erectile dysfunction, ejaculation disorder).
Both finasteride and dutasteride may reduce serum prostate-specific antigen (PSA) values by as much as 50%. The decrease in PSA is typically maximally achieved when the maximal decrease in prostatic volume is noted (6 months). Thus, one must take this into account when using PSA to screen for prostate cancer.
One prospective, randomized, double-blind study by the Enlarged Prostate International Comparator Study (EPICS) was conducted to compare the efficacy of dutasteride to that of finasteride in men with symptomatic BPH. While this study was conducted over the course of only one year, the data suggest that both of these drugs were similarly effective in reducing prostate volume, improving Qmax, and LUTS for this population. The long-term outcomes are yet to be investigated.^[11]
Because these drugs interfere with the metabolism of testosterone, they are contraindicated in children and pregnant females. In addition, pregnant females or those who are considering conception should not handle crushed or broken tablets because of the potential for absorption and subsequent potential risk to a male fetus.
In patients with LUTS and enlarged prostates, 5-alpha-reductase inhibitors are believed to be appropriate and effective treatment.

5-Alpha reductase inhibitors and prostate cancer

On June 9, 2011, the US Food and Drug Administration announced revisions to the prescribing information for 5-alpha reductase inhibitors (5-ARIs). These agents include finasteride (Proscar, Propecia) and dutasteride (Avodart, Jalyn). 5-ARIs are indicated for benign prostatic hypertrophy and alopecia.
Data from 2 large, randomized, controlled trials observed an increased risk of being diagnosed with a more serious form of prostate cancer (high-grade prostate cancer) in trial participants taking 5-ARIs. The 2 trials are the Prostate Cancer Prevention Trial (PCPT) and the Reduction by Dutasteride of Prostate Cancer Events (REDUCE) trial. Both of these trials observed a decreased incidence of prostate cancer overall when preventive treatment included 5-ARIs, but an increased incidence of high-grade prostate cancer in men taking dutasteride or finasteride compared with placebo.^{[12, 13]}
The revised prescribing information recommends that prior to initiating therapy with 5-ARIs, perform appropriate evaluations to rule out other urological conditions, including prostate cancer, that might mimic benign prostatic hyperplasia (BPH).

Next Section: Combination Therapy

Combination Therapy

The alpha-1-receptor blockers provide rapid relief, while the 5-alpha-reductase inhibitors target the underlying disease process.^[7] The Medical Therapy of Prostatic Symptoms (MTOPS) trial demonstrated that combination therapy reduced the risk of progression and produced a greater improvement in IPSS than therapy with finasteride or doxazosin alone. The risks of AUR and BPH-related surgery were reduced with combination therapy or finasteride in comparison with doxazosin monotherapy.^[14]
The Symptom Management After Reducing Therapy (SMART-1) trial demonstrated that after 6 months of combination therapy, discontinuation of the alpha-1-blocker is possible in men with moderate LUTS. However, those with severe LUTS may require longer combination therapy.^[14]

Anticholinergic Agents

Historically, anticholinergics were discouraged in men with BPH because of concerns of inducing urinary retention. Trials have demonstrated a slight increase in PVR; however, AUR rates were low. Importantly, these trials consisted of patients with low baseline PVR.
The 2010 AUA BPH guidelines recommend anticholinergic agents for management of LUTS in patients who do not have an elevated PVR and whose LUTS are primarily irritative. Baseline PVR should be obtained prior to initiation of anticholinergic therapy, to assess for urinary retention.^[15] Caution with anticholinergics is recommended with patients whose PVR is greater than 250-300 mL.^[2]

Landmark Clinical Trials

Numerous phase II and phase III trials of drugs used in the treatment of BPH have been conducted. A few landmark studies are selected below.
The Proscar Long-Term Efficacy and Safety Study (PLESS), patients treated with finasteride (5 mg/d) were at a significantly lower risk of developing AUR or needing surgery.^[16] This was a multicenter, 4-year, double-blind, placebo-controlled study of 3,040 men. Men with PSA levels of more than 10 ng/mL and those with prostate cancer were excluded.
The Medical Therapy of Prostatic Symptoms (MTOPS) trial demonstrated that combination therapy with doxazosin and finasteride was well tolerated, and was superior to placebo and monotherapy with either agent. The primary endpoints of the study were reduction in AUA-SI score, AUR, recurrent infections, renal insufficiency, incontinence, changes in flow, and PSA level and a lower rate of invasive treatments. MTOPS was a multicenter, 4- to 6-year, double-blind, randomized, placebo-controlled trial of 3,047 men with symptomatic BPH.^[17]
In the Alfuzosin Long-Term Efficacy and Safety Study (ALTESS), alfuzosin (10 mg/d) decreased the risk of LUTS deterioration and significantly improved QOL and peak urinary flow rate. ALTESS was a 2-year, double-blind, placebo-controlled study of 1,522 men. Notably, these men had greater risk factors for BPH progression (ie, older age, higher IPSS scores, larger prostate size, lower Qmax, and higher PVR) than those in the MTOPS trial. Alfuzosin did not reduce the risk of AUR but tended to reduce the risk of surgery.^[18]
In the international real-life practice study of alfuzosin once daily (ALF-ONE), 3 years of alfuzosin (10 mg/d) decreased IPSS by one third, with significant improvements in nocturia and bother score. ALF-ONE was conducted in 689 European men with a mean age of 67.6 years. Clinical progression of worsening of IPSS (≥4 points) was seen in 12.4%, AUR in 2.6%, and requirement of BPH-related surgery in 5.7%. Alfuzosin was well tolerated, with dizziness the most common adverse effect (4.5%). Notably, symptom worsening during treatment and high PSA levels appeared to be the best predictors of clinical progression.^[19]
Four-year results in the Combination of Avodart and Tamsulosin (CombAT) study revealed that for men with prostate volumes of 30-58 mL, combination therapy with dutasteride (dual 5-alpha-reductase inhibitor) and tamsulosin (alpha-1-blocker) improved symptoms, urinary flow, and QOL better than monotherapy with either drug, although not in men who had a prostate volume of 58 mL or more.^[20] The adverse-effect profile of combination therapy was similar to that of monotherapy, although drug-related adverse events were more common with combination therapy.^[21] CombAT is a 4-year, multicenter, randomized, double-blind, parallel group study of 4,844 men aged 50 years or older with moderate-to-severe BPH symptoms (IPSS ≥12), prostate volume of 30 mL or greater, and a PSA level of 1.5-10 ng/mL. This study contributes to the standard of care shifting towards combined drug therapy in appropriately selected patients, while better defining the role of the alpha-blockers.^[15]

Phytotherapeutic Agents and Dietary Supplements

Phytotherapeutic agents and dietary supplements are considered emerging therapy by the AUA Guidelines panel and are not recommended for the treatment of BPH because of the lack of evidence at this time.
Pharmaceuticals derived from plant extracts are widely used throughout the world for the treatment of various medical ailments. In 1998, Americans spent a total of $3.65 billion on all herbal remedies. In France and Germany, plant extracts have a market share of up to 50% of all drugs prescribed for symptomatic BPH. In the United States, these agents are also popular and readily available.
The attraction to phytotherapeutic agents appears to be related to the perception of therapeutic healing powers of natural herbs, the ready availability, and the lack of adverse effects.
Most of the phytotherapeutic agents used in the treatment of LUTS secondary to BPH are extracted from the roots, seeds, bark, or fruits of plants listed below. Some suggested active components include phytosterols, fatty acids, lectins, flavonoids, plant oils, and polysaccharides. Some preparations derive from a single plant; others contain extracts from 2 or more sources.
Each agent has one or more proposed modes of action. The following modes of action are suggested:

• Antiandrogenic effect
• Antiestrogenic effect
• Inhibition of 5-alpha-reductase
• Blockage of alpha receptors
• Antiedematous effect
• Anti-inflammatory effect
• Inhibition of prostatic cell proliferation
• Interference with prostaglandin metabolism
• Protection and strengthening of detrusor

The origins of phytotherapeutic agents are as follows:

• Saw palmetto, (American dwarf palm; Serenoa repens, Sabal serrulata) fruit
• South African star grass (Hypoxis rooperi) roots
• African plum tree (Pygeum africanum) bark
• Stinging nettle (Urtica dioica) roots
• Rye (Secale cereale) pollen
• Pumpkin (Cucurbita pepo) seeds

Saw palmetto (American dwarf palm)

Extracts of saw palmetto berries are the most popular botanical products for BPH. The active components are believed to be a mixture of fatty acids, phytosterols, and alcohols. The proposed mechanisms of action are antiandrogenic effects, 5-alpha-reductase inhibition, and anti-inflammatory effects.
The recommended dosage is 160 mg orally twice daily. Studies show significant subjective improvement in symptoms without objective improvements in urodynamic parameters. Minimal adverse effects include occasional GI discomfort.
The 2010 AUA guidelines, based on more recent studies, do not detect a clinically meaningful effect of saw palmetto on LUTS. Further clinical trials are underway.^[2] In fact, in a double-blind, multicenter, placebo-controlled randomized trial at 11 North American clinical sites, saw palmetto extract was studied at up to 3 times the standard dose on lower urinary tract symptoms attributed to BPH. Saw palmetto extract was no more effective than placebo on the American Urological Association Symptom Index. No clearly attributable adverse effects were identified. Similar to the Saw Palmetto Treatment for Enlarged Prostates (STEP) study, saw palmetto was not found to be beneficial for the treatment of LUTS in men.^[22]

African plum tree (P africanum)

Suggested mechanisms of action include inhibition of fibroblast proliferation and anti-inflammatory and antiestrogenic effects. This extract is not well studied.

Rye (S cereale)

This extract is made from pollen taken from rye plants growing in southern Sweden. Suggested mechanisms of action involve alpha-blockade, prostatic zinc level increase, and 5-alpha-reductase activity inhibition. Significant symptomatic improvement versus placebo has been reported.

Treatment of Concomitant Erectile Dysfunction

It is recommended to first establish the alpha-1 blocker dose before treating the erectile dysfunction. The medication used to treat erectile dysfunction should be titrated to the lowest effective dose. Furthermore, sildenafil doses of greater than 25 mg should not be taken within 4 hours of any alpha-blocker.^{[23, 24, 25]}
In addition to treating erectile dysfunction, sildenafil may improve mild-to-moderate LUTS. Nitric oxide may mediate relaxation of the prostatic urethra and/or bladder neck. The utility of phosphodiesterase inhibitors in the treatment of LUTS has yet to be defined.^[26]
Recent trials have addressed the use of long-acting phosphodiesterase type 5 inhibitors (tadalafil) and have found them to be significantly better than placebo in improving the symptoms of BPH/LUTS.

Transurethral Resection of the Prostate

TURP is considered the criterion standard for relieving BOO secondary to BPH. The indications to proceed with a surgical intervention include the following:

• AUR
• Failed voiding trials
• Recurrent gross hematuria
• Urinary tract infection
• Renal insufficiency secondary to obstruction

Additional indications for surgical intervention include failure of medical therapy, a desire to terminate medical therapy, and/or financial constraints associated with medical therapy. However, TURP carries a significant risk of morbidity (18%) and mortality risk (0.23%). More recent techniques using bipolar cautery resection devices have lowered the morbidity associated with TURP.
TURP is performed with regional or general anesthesia and involves the placement of a working sheath in the urethra through which a hand-held device with an attached wire loop is placed. High-energy electrical cutting current is run through the loop so that the loop can be used to shave away prostatic tissue. The entire device is usually attached to a video camera to provide vision for the surgeon.
Although TURP is often successful, it has significant drawbacks. When prostatic tissue is cut away, significant bleeding may occur, possibly resulting in termination of the procedure, blood transfusion, and a prolonged hospital stay.
Irrigating fluid may also be absorbed in significant quantities through veins that are cut open, with possible serious sequelae termed transurethral resection syndrome (TUR syndrome). However, this is very rare and does not occur with saline irrigation used in bipolar devices. A urinary catheter must be left in place until the bleeding has mostly cleared.
The large working sheath combined with the use of electrical energy may also result in stricturing of the urethra.
The cutting of the prostate may also result in a partial resection of the urinary sphincteric mechanism, causing the muscle along the bladder outlet to become weak or incompetent. As a result, when the patient ejaculates, this sphincteric mechanism cannot keep the bladder adequately closed. The ejaculate consequently goes backwards into the bladder (ie, retrograde ejaculation), rather than out the penis. Additionally, if the urinary sphincter is damaged, urinary incontinence may result.
The nerves associated with erection run along the outer rim of the prostate, and the high-energy current and/or heat generated by such may damage these nerves, resulting in impotence.
TURP usually requires hospitalization.

Open Prostatectomy

This procedure is now reserved for patients with very large prostates (>75 g), patients with concomitant bladder stones or bladder diverticula, and patients who cannot be positioned for transurethral surgery.
Open prostatectomy requires hospitalization and involves the use of general/regional anesthesia and a lower abdominal incision. The inner core of the prostate (adenoma), which represents the transition zone, is shelled out, thus leaving the peripheral zone behind. This procedure may involve significant blood loss, resulting in transfusion. Open prostatectomy usually has an excellent outcome in terms of improvement of urinary flow and urinary symptoms.
More recently, laparoscopic simple prostatectomy has been performed at a number of institutions and appears to be feasible. However, prostatectomy performed in this fashion still appears to be associated with risk for significant blood loss. Experience to date with this procedure is limited.^[27]

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Minimally Invasive Treatment

There is considerable interest in the development of other therapies to decrease the amount of obstructing prostate tissue while avoiding the above-mentioned adverse effects associated with TURP. These therapies are collectively called minimally invasive therapies.
Most minimally invasive therapies rely on heat to destroy prostatic tissue. This heat is delivered in a limited and controlled fashion, in the hope of avoiding the complications associated with TURP. They also allow for the use of milder forms of anesthesia, which translates into less anesthetic risk for the patient.
Heat may be delivered in the form of laser energy, microwaves, radiofrequency energy, high-intensity ultrasound waves, and high-voltage electrical energy. As in TURP, delivery devices are usually passed through a working sheath placed in the urethra, although they are usually of a smaller size than that needed for TURP. Devices may also simply be attached or incorporated into a urinary catheter or passed through the rectum, from which the prostate may also be accessed.
Keep in mind that many of these minimally invasive therapies are undergoing constant improvements and refinements, resulting in increased efficacy and safety. Ask urologists about the specifics of the minimally invasive therapies that they use and what results they have experienced.

Transurethral Incision of the Prostate

Transurethral incision of the prostate (TUIP) has been in use for many years and, for a long time, was the only alternative to TURP. It may be performed with local anesthesia and sedation. TUIP is suitable for patients with small prostates and for patients unlikely to tolerate TURP well because of other medical conditions. TUIP is associated with less bleeding and fluid absorption than TURP. It is also associated with a lower incidence of retrograde ejaculation and impotence than TURP.

Lasers

Lasers deliver heat to the prostate in various ways. Lasers heat prostate tissue, causing tissue death by coagulative necrosis, with subsequent tissue contraction; however, laser coagulation of the prostate in this specific sense has met with limited results.
Lasers have also been used to directly evaporate, or to melt away, prostate tissue, which is more effective than laser coagulation. Photoselective vaporization of the prostate produces a beam that does not directly come into contact with the prostate; rather, it delivers heat energy into the prostate, resulting in destruction/ablation of the prostate tissue.
Potassium-titanyl-phosphate (KTP) and holmium lasers are used to cut and/or enucleate the prostate, similar to the TURP technique. These are widely used laser techniques.
Transurethral vaporization/ablation with the KTP or holmium laser can be performed with general or spinal anesthesia and can be performed in an outpatient setting. Catheter time usually lasts less than 24 hours. Studies suggest that photoselective vaporization of the prostate can significantly improve and sustain symptomatic and urodynamic outcomes.
This procedure has been quite useful in patients who require anticoagulation for various medical conditions, since anticoagulation does not need to be interrupted for this procedure, thus further decreasing patient risk.^{[28, 29]}
Lasers may be used in a knifelike fashion to directly cut away prostate tissue (ie, holmium laser enucleation of the prostate), similar to a TURP procedure. The holmium laser allows for simultaneous cutting and coagulation, making it quite useful for prostate resection. Laser enucleation of the prostate has proved to be safe and effective for treatment of symptomatic BPH, regardless of prostate size, with low morbidity and short hospital stay.
TUR syndrome is not seen with this technique, because iso-osmotic saline is used for irrigation. Additionally, removed prostatic tissue is available for histologic evaluation, whereas vaporization/ablation technique does not provide tissue for evaluation. Holmium laser enucleation of the prostate may prove to be the new criterion standard for surgical management of BPH.^{[29, 30]}
Laser treatment usually results in decreased bleeding, fluid absorption, and length of hospital stay, as well as decreased incidence of impotence and retrograde ejaculation when compared with standard TURP. However, healing from laser treatment does not occur until after a period when dead cells slough; thus, patients may experience urinary urgency or irritation, resulting in frequent or uncomfortable urination for a few weeks.
The results of laser therapy vary from one another because not all wavelengths yield the same tissue effects. For example, interstitial lasers (eg, indigo lasers) are designed to heat tissue within the confines of the prostate gland and spread radiant energy at relatively low energy levels. They do not directly involve the urethral portion; thus, irritative symptoms following the procedure are potentially reduced.
Contact lasers such as KTP or holmium, on the other hand, are designed to cut and vaporize at extremely high temperatures They usually bring about more relief of urinary symptoms than treatment with medicines, but not always as much as is provided with TURP. However, KTP laser vaporization and holmium laser enucleation yield results that rival those of TURP.

Transurethral Microwave Therapy

The use of microwave energy, termed transurethral microwave therapy (TUMT), delivers heat to the prostate via a urethral catheter or a transrectal route. The surface closest to the probe (the rectal or urethral surface) is cooled to prevent injury. The heat causes cell death, with subsequent tissue contraction, thereby decreasing prostatic volume.
TUMT can be performed in the outpatient setting with local anesthesia. Microwave treatment appears to be associated with significant prostatic swelling; a considerable number of patients require a urinary catheter until the swelling subsides. In terms of efficacy, TUMT places between medical therapy and TURP. The 2010 AUA guidelines state TUMT is an effective option for partially relieving symptoms that may be considered in patients with moderate or severe LUTS secondary to BPH.^[31]

Transurethral Needle Ablation of the Prostate

Transurethral needle ablation of the prostate (TUNA) involves using high-frequency radio waves to produce heat, resulting in a similar process of thermal injury to the prostate as previously described. A specially designed transurethral device with needles is used to deliver the energy.
TUNA can be performed under local anesthesia, allowing the patient to go home the same day. Similar to microwave treatment, radiofrequency treatment is quite popular, and a number of urologists have experience with its use. Radiofrequency treatment appears to reliably result in significant relief of symptoms and better urine flow, although not quite to the extent achieved with TURP. The 2010 AUA guideline update considers TURP an appropriate and effective treatment option for moderate or severe LUTS.^[2]

High-Intensity Ultrasound Energy Therapy

High-intensity ultrasound energy therapy delivers heat to prostate tissue, with the subsequent process of thermal injury. High-intensity ultrasound waves may be delivered rectally or extracorporeally and can be used with the patient on intravenous sedation. Urinary retention appears to be common with its use.
High-intensity ultrasound energy also produces moderate results in terms of improvement of the urinary flow rate and urinary symptoms, although its use is now relatively limited compared with the more popular TUNA and TUMT.
High-intensity ultrasound is considered investigational at this time and should not be offered outside of clinical trials.

Mechanical Approaches

Mechanical approaches are used less commonly and are usually reserved for patients who cannot have a formal surgical procedure. Mechanical approaches do not involve the use of energy to treat the prostate.
Prostatic stents are flexible devices that can expand when put in place to improve the flow of urine past the prostate. Their use has been associated with encrustation, pain, incontinence, and overgrowth of tissue through the stent, possibly making their removal quite difficult. To date, their full role and long-term effects are not fully known.

Diet

Data from the Prostate Cancer Prevention Trial revealed that a diet low in fat and red meat and high in protein and vegetables may reduce the risk of symptomatic BPH. Additionally, regular alcohol consumption was associated with a reduced risk of symptomatic BPH, but this is to be interpreted cautiously given the untoward effects of excessive alcohol consumption.^[32]

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Long-term Monitoring

Patients with BPH who have symptoms significant enough to be placed on medication should be evaluated during office visits to discuss the efficacy of the medication and potential dose adjustment. These visits should take place at least biannually. Patients should undergo DRE and PSA screening at least annually.