BPH
Diagnosis and
Medical Treatment
BPH
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The most common disease of aging men
Present in majority of men
Prevalence : 60yr : 50%↑
85yr : 90%
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Wide variance in symptoms
Large prostate does not equal voiding
problems
LUTS
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Morbidity & Complication of BPH
Mortality of BPH : Rare
LUTS : Bothersome
Highly variable
Treatment :
Patient’s perception
Degree of interfering life style
Definitions and Terminology
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BPH : Stromal and epithelial
hyperplasia in periuretheral zone
LUTS : Lower urinary tract symptoms
The relationship of BPH & LUTS : Complex
LUTS or LUTS suggestive of BPH >> prostatism
BPH : Bothersome LUTS by histological BPH
or increased tone of the prostate
LUTS
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Irritative versus Obstructive
Irritative
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Obstructed
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Frequency/urgency/nocturia
Slow stream/stranguria/start-stop
Difficult to distinguish by history alone
since symptoms overlap
Initial Evaluation
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History
DRE & Focused PE
UA
PSA in select patients
AUA/IPSS Sx Index, Bother
Medical History
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Surgery, general health
Voiding History: polyuria, stranguria,
frequency, urgency post void dribbling
Voiding diary (nocturia)
Urinary Infections :culture
Incontinence
Physical Examination
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DRE
Neurologic exam
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Mental status
Ambulatory status
Neuromuscular function
Anal sphincter tone
Urinalysis
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Bladder cancer, CIS
UTI, Urethral stricture
Urethral, bladder stones
PSA
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Screening for cancer
10 year life expectancy and for whom the
presence of cancer would change
management
One predictor of natural Hx of BPH
Optional Initial Test
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Urine Cytology : Bladder Ca, CIS
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Predominantly irritative Sx
Smoking or other risk factors
Serum Creatinine : Not recommended
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Renal insufficiency : 1%↓
Not more common than general population
Non BPH cause as diabetic nephropathy
Symptom Assessment
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Sx alter QOL
Sx quantification
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Severity of disease
Response of therapy
Sx progression
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0~7 : mild
8~19 : moderate
20~35 : severe
Not a replacement for personal discussion of Sx
with the patient
Symptom Assessment
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IPSS : Recommended
Other validated assessment : optional
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Frequency and severity of LUTS
Bother score
Interference with daily activities
Urinary incontinence
Sexual function
Health related – QOL
ICS Questionnaire, DPSS, BPH impact index,
IPSS QOL, Sexual function Questionnaire
QOL
Optional Diagnostic Test
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Uroflometry measures rate of urine flow
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Not a first line test
Post-void residual urine (PVR) useful tool
for evaluation and treatment
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Non-prostatic case of Sx
Selection of invasive Tx
Prior failed BPH Tx
Quantitative method to diagnose and follow
result of treatment
Qmax : rate of urine flow
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Predict the response to surgery
Predict the natural Hx of BPH
Advantages
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LUTS with Normal Qmax : non prostatic cause
Qmax < 10ml/sec : obstruction
Disadvantages
Sx response is not dependent on Qmax
 Test / retest variability, lack of well designed
study
→ Not feasible to establish cut-point
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PVR
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Bladder dysfunction
Identifies favorable response to Treatment
Progression of disease
Clinical tool not a singular diagnostic test
Test / retest variability
Lack of outcome studies
No PVR cut-point
Optional
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Doesn’t predict the response to medical Tx
Elevated PVR without UTI, renal insufficiency,
bothersome Sx
- No level of RU mandates invasive Tx
Optional Diagnostic Tests Who
Choose Invasive Tx
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Pr-flow study
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Qmax > 10ml/sec & surgery considered
Prior failed surgery
Neurologic disease
Not indicated to predict response to medical Tx
Cystoscopy : Hematuria, urethral stricture
r/o Bladder Ca, prior surgery
TRUS : Size & shape, selection of surgery
CMG, IVP, USG of Kidney
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Not recommended
Indicated in Hematuria, UTI
Renal insufficiency, stone Hx, upper tract
surgery Hx
Initial Management and
Discussion of Treatment Options
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Watchful waiting
Medical therapy – pills
Minimally invasive surgery
Surgery
Treatment
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Watchful waiting
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Mild Symptoms
Mod or severe Symptoms without Renal
insufficiency, UTI, retention
Increase water intake↓
Decrease alcohol↓, Caffeine↓ SODA
DRE, PSA : suggests natural Hx of Sx
flow rate, AUR, surgery
Medical Treatment Options
1.
2.
3.
4.
Alpha-adrenergic blockers
5 alpha-reductase inhibitors
Combination therapies
Phytotherapy
Alpha-adrenergic Blockers
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Opens prostatic urethra by relaxing
smooth muscle in prostate
Doxazosin, terazosin, flomax, uroxatrol
and rapaflo
Equal effectiveness
Differences in adverse events
LUTS secondary to BPH
Very effective in relieving symptoms of
BPH
Alpha-adrenergic Blockers
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Side Effects: postural hypotension,
retrograde ejaculation
Hypertension and cardiac risk factors
LUTS – Alpha blocker only: incidence of
CHF
Patients with hypertension : separate
management of hypertension
May make cataract surgery difficult
(floppy iris syndrome)
5 Alpha-reductase Inhibitors
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Reduces prostate volume 25-28%
Reducing volume doesn’t always relieve
obstruction
Symptomatic prostatic enlargement
treatment helps to prevent progression of
disease (AUR, surgery)
Sexual dysfunction, long-term Tx
Not appropriate for men with LUTS
without prostatic enlargement
Natural History of BPH
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PLESS study
1. 3,040 clinical BPH patients
2. IPSS: moderate to severe
3. Qmax: <15 ml/s
4. DRE: enlarged prostate gland
5. PSA <10 ng/ml
(PSA 4-9.9: negative biopsy)
6. Follow-up: 4 years
Natural History of BPH
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Risk of Acute Urinary Retention or Surgery
Natural History of BPH
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Change of Symptom Score
Natural History of BPH
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Change of Peak Urinary Flow Rate
Surgery
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Minimally Invasive (office)
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Microwave
TUNA
Interstitial Laser
Surgery (operating room)
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TURP
HOLAP
HOLEP
Surgery
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Patient selection determines type of
procedure offered
Surgery very effective in properly selected
patients
Majority of patients stop medications
Absolute indications
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Retention
Recurrent infections
Bleeding
Stones
Surgery
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Absolute Indications
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Retention
Repeated infection
Bladder stones
Relative indications
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Worsening symptoms
Rising urine retention
Desire to stop medication
Surgery
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Minimally invasive surgery
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Better symptom results than medication
Minimal recovery – days
Low incidence of long-term side effects
No incontinence after treatment
Higher future retreatment rates than surgery
Not effective for patients in urine retention
Excellent alternative to medication
Surgery
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OR based surgery
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Most effective means of relieving prostate
obstruction
Requires general/spinal anesthesia
Removal of prostate tissue
Variety of energies used to remove tissue
Requires catheters after treatment
Usually involves hospitalization
Surgery
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Indicated for urine retention
Highest side effects
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Possible incontinence
Retrograde ejaculation
Best treatment outcomes
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Improves flow rate
Lowers voiding symptoms
Recommendations
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Goal directed therapy
Most patients have a variety of treatment
options
Medical management works well for most
patients with minimal side effects
Modern procedures are effective and safe
Informed patient decision making :
benefits, risks, costs