BPH

Question 1

Initial Eval

Answer 1

The initial evaluation should include:

• a medical history to identify other causes of voiding dysfunction or comorbidities that may complicate treatment;
• a physical examination, including both digital rectal and focused neurological examinations;
• a urinalysis performed by dipstick testing or microscopic examination of the sediment to screen for hematuria, glucose and urinary tract infection (UTI)
• and measurement of the serum prostate-specific antigen (PSA) offered to patients 1) with at least a 10-year life expectancy and for whom knowledge of the presence of prostate cancer would change management, or 2) for whom the PSA measurement may change the management of the patient’s voiding symptoms. Frequency volume charts should be used when nocturia is the dominant symptom, and also in other settings. Urine cytology is an optional test in men with a predominance of irritative symptoms, especially with a history of smoking or other risk factors, to aid in the diagnosis of bladder carcinoma in situ and bladder cancer. The routine measurement of serum creatinine levels is not recommended.

Question 2

Symptom assessment

Answer 2

Symptom quantification is important to determine disease severity, document therapeutic response to therapy and detect symptom progression in men managed by watchful waiting.

• Administer the AUA Symptom Index (identical to the seven symptom questions of the International Prostate Symptom Score [IPSS]).
• Administer other validated assessment instruments, including the BPH Impact Index, if warranted.

Question 3

Other tests

Answer 3

• Additional diagnostic tests (pressure-flow urodynamics studies, urethrocystoscopy and ultrasound [transabdominal or transrectal]) are not recommended in the initial evaluation of LUTS but are optional in the following settings when choosing invasive therapies, particularly if the outcome of the pressure-flow study may impact choice of intervention, or if prostate size and anatomical configuration are important considerations for a given treatment modality.
• Urinary flow rate recording and measurement of post-void residual urine usually are not necessary prior to the institution of watchful waiting or medical therapy. However, they may be helpful in patients with a complex medical history, those with persistent or bothersome LUTS after basic management and in those desiring invasive therapy.
• Filling cystometography and upper urinary tract imaging by ultrasonography or excretory urography are not recommended in the typical patient unless the patient has hematuria, UTI, renal insufficiency or a history of urolithiasis or urinary tract surgery.

Question 4

Initial management - mild symptoms

Answer 4

Patients with Mild Symptoms

• Watchful waiting is the treatment of choice in patients with mild symptoms of BPH (AUA Symptom Score <8 ) and patients with moderate or severe symptoms who are not bothered by their symptoms (i.e., do not interfere with the daily activities of living).
• A urologist should be consulted (if not done already) if a patient has persistent, bothersome LUTS after basic management.

Question 5

Initial management - moderate/severe symptoms

Answer 5

Patients with Moderate to Severe Symptoms

• Treatment options for patients with bothersome moderate to severe symptoms of BPH (AUA Symptom Score >8) include watchful waiting and the medical, minimally invasive or surgical therapies defined in Table 1.
• Explain the benefits and harms of the BPH treatment options (including watchful waiting) using the information provided in the full text document (on www.AUAnet.org), to patients with moderate to severe symptoms (AUA Symptom Score >8) who are bothered enough to consider therapy.

Question 6

Medical mgmt - alpha blocker

Answer 6

Watchful waiting is indicated for patients with mild or non-bothersome symptoms whose overall health is not compromised by bladder outlet obstruction.

Medical Treatment - Alpha-adrenergic Blockers

• Alfuzosin, doxazosin, tamsulosin and terazosin are appropriate treatment options for patients with LUTS secondary to BPH and are believed to have equal clinical effectiveness. These drugs should be the first treatment of choice when BO symptoms predominate.
• The older, less costly generic alpha blockers remain reasonable choices. These require dose titration and blood pressure monitoring.
• Physicians and patients should be aware that a surgical condition termed Intraoperative Floppy Iris Syndrome (IFIS) has been observed during cataract surgery in some patients treated with alpha-1 blockers. Most reports were in patients taking the alpha-1 blocker when IFIS occurred, but in some cases, the alpha-1 blocker had been stopped prior to surgery. The benefit of stopping alpha-1 blocker therapy prior to cataract surgery has not been established. Men with planned cataract surgery should avoid the initiation of alpha blockers until their cataract surgery is completed.
• Prazosin or phenoxybenzamine should not be used in this setting.

Question 7

Medical mgmt - 5 ARI

Answer 7

5 Alpha-reductase Inhibitors Finasteride and dutasteride are:

• Appropriate and effective treatments in patients with LUTS associated with demonstrable prostatic enlargement.
• Indicated for patients with symptomatic prostatic enlargement but no bother, to prevent disease progression. [Present the disadvantages of this approach (side effects and the need for long-term daily therapy) to the patient with an estimate of his baseline risk of progression to aid in informed decision making.]
• Not appropriate for men with LUTS without evidence of prostatic enlargement.
• Finasteride is an appropriate and effective treatment alternative in men with refractory hematuria presumably due to prostatic bleeding (i.e., after exclusion of any other causes of hematuria). A similar level of evidence concerning dutasteride was not reviewed; it is the expert opinion of the Panel that dutasteride likely functions in a similar fashion.
• Overall, there is insufficient evidence to recommend using 5-ARIs preoperatively in the setting of a scheduled TURP to reduce intraoperative bleeding or reduce the need for blood transfusions.

Question 8

medical mgmt - Anticholinergics

Answer 8

Anticholinergic Agents

• Are appropriate and effective in men with predominately irritative symptoms and without an elevated post-void residual (PVR).
• Baseline PVR should be assessed prior to starting anticholinergic therapy. Anticholinergics should be used with caution in patients with a post-void residual greater than 250 t300 mL.

Question 9

Medical mgmt - combo tx

Answer 9

Combination Therapy • Concomitant use of an alpha-adrenergic receptor blocker and a 5 alpha-reductase inhibitor – or an alpha-adrenergic receptor blocker and an anticholinergic – is an appropriate and effective treatment for patients with LUTS associated with demonstrable prostatic enlargement.

Question 10

Medical mgmt - Complementary and Alternative Medicines (CAM)

Answer 10

Complementary and Alternative Medicines (CAM)

• No dietary supplement, combination phytotherapeutic agent or other nonconventional therapy is recommended for the management of LUTS secondary to BPH.
• Available data do not suggest that saw palmetto has a clinically meaningful effect on LUTS secondary to BPH. Further clinical trials are in progress and the results of these studies will elucidate the potential value of saw palmettextracts in the management of patients with BPH.
• The paucity of published high quality, single extract clinical trials of Urtica dioica do not provide a sufficient evidence base with which to recommend for or against its use for the treatment of LUTS secondary to BPH.

Question 11

Minimally-invasive Surgical Therapies

Answer 11

Minimally-invasive Surgical Therapies Transurethral Microwave Heat Treatment (TUMT) and Transurethral Needle Ablation (TUNA)

• Transurethral needle ablation is an effective treatment in partially relieving symptoms of BPH.
• TUMT is effective in partially relieving LUTS secondary to BPH and may be considered in men with moderate or severe symptoms.

Question 12

Surgical Procedures

Answer 12

Surgical Procedures

• The patient may appropriately select a surgical intervention as his initial treatment if he has bothersome symptoms.
• Patients who have developed complications from BPH are best treated surgically.
• The choices of surgical approach (open or endoscopic) and energy source (electrocautery vs. laser, monopolar vs. bipolar approach) are technical decisions based on the patient’s prostate size, the individual surgeon’s judgment and the patient’s comorbidities.
• The choice of approach should be based on the patient’s individual presentation, including anatomy, the surgeon’s experience and discussion of the potential benefit and risks for complications.

Question 13

Prostatectomy

Answer 13

Prostatectomy

• Open prostatectomy is an appropriate and effective treatment alternative for men with moderate to severe LUTS and/or who are significantly bothered by these symptoms.
• Men with moderate to severe LUTS and/or who are significantly bothered by these symptoms can consider a laparoscopic or robotic prostatectomy.

Question 14

Laser Therapies

Answer 14

Laser Therapies

• Laser therapies are appropriate and effective treatment alternatives to transurethral resection of the prostate and open prostatectomy in men with moderate to severe LUTS and/or those who are significantly bothered by these symptoms.
• Laser therapies include: transurethral laser enucleation (holmium laser resection of the prostate [HoLRP], holmium laser enucleation of the prostate [HoLEP]), transurethral side firing laser ablation (holmium laser ablation of the prostate [HoLAP], and photoselective vaporization [PVP]). The choice of approach should be based on the patient’s presentation, anatomy, the surgeon’s level of training and experience and a discussion of the potential benefit and risks for complications.
• Generally, transurethral laser approaches have been associated with shorter catheterization time and length of stay, with comparable improvements in LUTS. There is a decreased risk of the perioperative complication of transurethral resection syndrome. Information concerning certain outcomes, including retreatment and urethral strictures, is limited due to short follow-up. • As with all new devices, comparison of outcomes between studies should be considered cautiously given the rapid evolution in technologies and power levels.
• Emerging evidence suggests a possible role of transurethral enucleation and laser vaporization as options for men with very large prostates (> 100 g). There are insufficient data on which to base comments on bleeding.

Question 15

Therapies for patients with uncommon or serious complications of BPH

Answer 15

Surgery is recommended for patients with the following complications:

• Refractory retention who have failed at least one attempt at catheter removal. In patients who are not surgical candidates, treatment with intermittent catheterization, an indwelling catheter or stent is recommended.
• Renal insufficiency clearly due to BPH. • Recurrent UTIs, recurrent gross hematuria or bladder stones clearly due to BPH and refractory to other therapies.
• A bladder diverticulum is not an absolute indication for surgery, unless it is associated with recurrent UTI or progressive bladder dysfunction.
• Concomitant administration of an alpha blocker is an option prior to attempted catheter removal in patients with urinary retention.

Question 16

Basic mgmt of men with luts

Answer 16

Question 17

Detailed mgmt of persistent bothersome luts after basic mgmt

Answer 17