This is the case of F.G.

, 56 year old male, married, Filipino, Catholic, currently residing in San Antonio, Binan, Laguna. Admitted for the first time in this institution last January 5, 2011.

 Hirap at meron dugo sa ihi. ( Difficulty in voiding and Presence of Blood in the Urine)

One week prior to admission he experienced pain during urination and found a tinge of blood in his urine. January 5,2011 : Patient continued to have the said symptom and at around 10PM was admitted to this institution.

Gen. Survey
Conscious, coherent (-) cyanosis

Vital Signs
BP- 110/70 mmHg RR-21 bpm PR-80 bpm Temp-36.7

Skin
HEENT
Dry skin, decreased skin turgor, pale Pink palpebral conjuctiva, anisteric sclera Symmetrical chest expansion Adynamic Precordium Non tender abdomen, NABS (+) Edema on both Upper and Lower Extremeties

Chest and Lungs

Heart

Abdomen

Extremities

Complete Blood Count Results:

Hct- 20.3 % Platelet- 22.6 WBC- 24.4 g/l (Elevated; NV= 4.3-10 g/l ) Granulocytes- 3 Lympho/Mono- 17 Hgb- 67 ** Elevated WBC is indicative of infection

Fasting Blood Sugar Normal

Result: 107 mg/dL ( NV= < 126 mg/dl )

BUN - Normal
Result : 17.4 mg/dL (NV= 7-21 mg/dL)

Serum Creatinine - Normal

Result: 1.0 mg/dL (NV= 0.60- 1.7 mg/dL)

Urinalysis - Normal

Color- yellow Specific Gravity- 0.010 pH- 7.5 Appearance- turbid Pus cells- 1-3 hpf Red cells- 15-25 hpf

Fecalysis - Normal
Color- dark brown Consistency- soft

(-) HPN (-) DM (-) Asthma

2008 Benign Prostatic Hyperplasia (-) Previous Hospitalizations

(+) Occasional alcoholic beverage drinker (-) Smoking (-) Allergy to food and drugs

Unremarkable

Benign Prostatic Hyperplasia

Urethritis Urolithiasis Bladder Neck Contracture

BPH is the most common benign tumor in males Characterized by hyperplasia of prostatic stromal and epithelial cells, resulting in the formation of large, fairly discrete nodules in the periurethral region (transition zone) of the prostate It is believed that the main component of the hyperplastic process is impaired cell death

Overall reduction of the rate of cell death, resulting in the accumulation of senescent cells in the prostate The main androgen in the prostate, constituting 90% of total prostatic androgens, is dihydrotestosterone (DHT)

Formed in the prostate from the conversion of testosterone by the enzyme type 2 5reductase

Located almost entirely in stromal cells

epithelial cells of the prostate do not contain type

2 5 reductase, with the exception of a few basal cells stromal cells are responsible for androgendependent prostatic growth

DHT is more potent androgen than testosterone

higher affinity for androgen receptor (AR)

Binding of DHT to AR activates the transcription of androgen-dependent genes

DHT is not a direct mitogen for prostate cells

DHT-mediated transcription of genes results in

the increased production of several growth factors and their receptors fibroblast growth factor (FGF) family, and particularly FGF-7 (keratinocyte growth factor)

FGF-7, produced by stromal cells, is probably the most important factor mediating the paracrine regulation of androgen-stimulated prostatic growth. Other growth factors produced in BPH are FGFs 1 and 2, and TGF, which promote fibroblast proliferation.

Obstructive Symptoms
Hesitancy Decreased force and caliber of stream

Sensation of incomplete bladder emptying

Double voiding Straining to urinate Postvoid dribling

Irritative Symptoms
secondary response of the bladder to the increased outlet resistance

Urgency
Frequency Nocturia

Digital Rectal Exam

Smooth, firm, elastic enlargement of the prostate

Urinalysis Serum Creatinine Postvoid Residual Urine Ultrasound Urethrocystoscopy

mild (0 to 7), moderate (8 to 19), or severe (20 to 35)

Watchful Waiting Medical Therapy

- Blockers

5- Reductase Inhibitors
Combination Therapy Phytotherapy

Conventional Surgical Therapy

Transurethral resection of the Prostate ( TURP) Transurethral Incision of the Prostate

Open Simple Prostatectomy

Minimally Invasive Therapy

Laser Therapy (TULIP) Transurethral Needle Ablation of the Prostate

(TUNA) Transurethral Electrovaporization of the Prostate

DRUG
Finasteride

E (Effectivity) ++++

S (Safety) +++

S (Suitability) ++++

A (Affordability) ++++ (P 44.40)

Total
15

Tamsulosin
Terazosin Doxazosin

+++
++ ++

+++
+ ++

+++
++ +

++ (P 88.00)
+ (P 153.50) +++ (P 69.00)

11
6 8

Finasteride (5- Reductase Inhibitor)

Steroid like 5-alpha reductase inhibitor which interfere with the effect of certain male hormones (androgens) on the prostate. Blocks the conversion of testosterone to DHT Causes reduction in DHT levels that begins within 8 hours after administration and lasts for about 24 hours.

Absorption: Absorbed from the GI tract (oral); peak plasma concentrations after 1-2 hr. Distribution: Protein-binding: 90%. Metabolism: Hepatic. Excretion: Urine and feces (as metabolites); <60 yr: 6 hr; >70 yr: 8 hr (elimination half-life)

Effect of Finasteride in decreasing the size of the prostate can be seen only if patient continues to take the medication for at least 6 months.

Hypersensitivity to one of its components Pregnancy Hypertension

If patient is hypertensive it is best to use

- Blockers ( Tamzolasin, Alfazosin )

Undiagnosed Prostate Cancer

Finasteride lowers Serum PSA levels masking the

diagnosis of Prostate CA

Liver Dysfunction
It is extensively metabolized in the liver

Obstructive Uropathy

Impotence - (1.1 -18.5%) Abnormal Ejaculation (7.2%) Decreased Ejaculatory Volume ( 0.9-2.8%) Abnormal Sexual Function ( 2.5%) Gynecomastia (2.2%) Erectile Dysfunction ( 1.3%) Ejaculatory Disorder (1.2%) Testicular Pain

Name: Myk Pizzaro Address: Molino, Cavite

Date: 10/14/2011 Age/Sex: 50/M

RX:

FINASTERIDE ( Atepros )

5mg/tab

#30

Sig: take 1 tab everyday for 1 month Refill: None Follow-Up: to be seen on 11/10/2011

Paul Andrew M. Gorospe, MD Lic. Number: 123456 PTR Number: 123456

P P