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CUA GUIDELINE: MALE LUTS/BPH 2018

See Original Guidelines

See AUA BPH Surgery Guidelines 2018

Background

• These guidelines are directed toward the typical male patient age > 50, presenting with LUTS and benign prostatic enlargement (BPE) and/or benign prostatic obstruction (BPO).

Diagnostic and Evaluation

• Mandatory (2):
1. History (symptom severity and bother, medical history) + physical exam (including DRE)
2. Urinalysis (routine and microscopic, culture and sensitivity)
• Recommended (2):
1. Symptom inventory (should include bother assessment), for example International Prostate Symptom Score (IPSS) or AUA Symptom Score, is recommended for an objective assessment of symptoms at initial contact, for follow-up of symptom evolution for those on watchful waiting, and for evaluation of response to treatment.
• IPSS domains FUNWISE + QOL
• Frequency
• Urgency
• Nocturia
• Weak stream
• Intermittency
• Straining
• Emptying, incomplete
• +Quality of life
• IPSS score:
• Mild: 1-7
• Moderate: 8-18
• Severe: 19-35
2. PSA (selected patients): should be offered to patients who have ≥ 10-year life expectancy and for whom knowledge of the presence of prostate cancer would change management, as well as those for whom PSA measurement may change the management of their voiding symptoms (estimate for prostate volume). Among patients without prostate cancer, serum PSA may also be a useful surrogate marker of prostate size and may also predict risk of BPH progression.
• Optional (6):
• In cases where the physician feels it is indicated, it is reasonable to proceed with one or more of the following:
1. Uroflowmetry
2. Post-void residual (recommend frequency volume chart for men with suspected nocturnal polyuria)
3. Serum creatinine
4. Urine cytology (if irritative symptoms are significant component of LUTS)
5. Voiding diary
6. Sexual function questionnaire
• Not Recommended, but may be required in patients with a definite indication, such as hematuria, uncertain diagnosis, DRE abnormalities, poor response to medical therapy, or for surgical planning.
• Cystoscopy
• Prostate ultrasound
• Urine cytology
• Urodynamics
• Upper urinary tract imaging
• Prostate biopsy
• Preoperative testing
• Determination of prostate size and extent of median lobe are related to procedure-specific indications.
• Cystoscopy should be performed to evaluate prostate size, as well as presence or absence of significant middle/median lobe.
• Ultrasound is recommended if further information in regard to size of prostate and extent of median lobe presence is required when choosing modality of surgical therapy.

Management

• Based on severity of symptoms
• Mild symptoms (e.g., IPSS <7): combination of lifestyle modification and watchful waiting
• Patients with mild symptoms and severe bother should undergo further assessment
• Bothersome, moderate (e.g., IPSS 8 – 18) and severe (e.g., IPSS 19 – 35) symptoms (3):
1. Watchful waiting/lifestyle modification
2. Medical therapy
3. Minimally invasive or surgical therapies

 

• First-line: lifestyle modifications with watchful waiting
• Patients on watchful waiting should have periodic physician-monitored visits.
• Risk factors for progression (symptoms, acute urinary retention or future need for BPH-related surgery) (4):
  1. Age > 50
  2. LUTS severity
  3. Prostate volume >30 cc
  4. Serum PSA >1.4 ng/mL
• A variety of lifestyle changes may be suggested for patients with non-bothersome symptoms (6):
1. Fluid restriction particularly prior to bedtime
2. Avoidance of caffeinated beverages, spicy foods
3. Avoidance/monitoring of some drugs (e.g., diuretics, decongestants, anti-histamines, anti-depressants)
4. Timed or organized voiding (bladder retraining)
5. Pelvic floor exercises
6. Avoidance or treatment of constipation

 

• Second-line: Medical treatment
• See Pharmalogical Managements of LUTS Chapter Notes
• Alpha-blockers
• Appropriate treatment options for LUTS secondary to BPH (5):
  • Non-selective: terazosin, alfuzosin, doxazosin
  • Selective: silodosin (most selective for alpha-1a), tamsulosin
• Although there are differences in the adverse event profiles of these agents, all 5 agents appear to have equal clinical effectiveness. The choice of agent should depend on the patient’s comorbidities, side effect profiles, and tolerance.
• Alpha-blockers do not alter the natural progression of the disease (little impact on prostate growth, the risk of urinary retention or the need for BPH-related surgery).
• Adverse events
  • Most common: dizziness (2–10%, with the highest rates for terazosin and doxazosin)
    • Terazosin and doxazosin require dose titration and blood pressure monitoring.
  • Ejaculatory disturbances are most often reported with tamsulosin and silodosin.
  • Floppy iris syndrome has been reported in patients on alpha-blockers, particularly tamsulosin, but this does not appear to be an issue in men with no planned cataract surgery and can be managed by the ophthalmologist, who is aware that the patient is on the medication.
• We recommend alpha-blockers as an excellent first-line therapeutic option for men with symptomatic bother who desire treatment
• 5 alpha-reductase inhibitors (5-ARIs)
• 5-alpha reductase converts testosterone to DHT. Use of 5-ARI results in increased serum testosterone and increased intraprostatic testosterone
• 5-ARIs improve symptoms, cause a modest (25–30%) shrinkage of the prostate, and can alter the natural history of BPH through a reduction in the risk of acute urinary retention (AUR) and the need for surgical intervention.
• Efficacy is noted in patients with a prostate volume >30 cc (and/or PSA levels >1.5 ng/ml)
• Adverse events:
  • Erectile dysfunction
  • Decreased libido
  • Ejaculation disorders
  • Gynecomastia (rarely)
• The 5-ARIs (dutasteride and finasteride) are appropriate and effective treatments for patients with LUTS associated with demonstrable prostatic enlargement
• Combination therapy
• Alpha-blocker with 5-ARI
  • See Pharmalogical Managements of LUTS Chapter Notes for details on MTOPS and CombAT
  • Significantly improves symptom score and peak urinary flow compared with either of the monotherapy options
  • Significantly Decreases risk of urinary retention and/or prostate surgery, but also the additive side effects of dual therapy (in particular ejaculatory disturbances).
  • Appropriate and effective treatment strategy for patients with LUTS associated with prostatic enlargement (> 30 or 35 cc).
  • Patients successfully treated with combination therapy may be given the option of discontinuing the alpha-blocker after 6-9 months of therapy. If symptoms recur, the alpha-blocker should be restarted.
• Anti-cholinergics with beta-3-agonists
  • For selected patients with bladder outlet obstruction due to BPH and concomitant detrusor overactivity, combination therapy with an alpha-block and anti-cholinergic or beta-3-agonist can be helpful.
  • Caution is recommended, however, when considering these agents with (3):
    1. Elevated residual urine volume (with PVR >250–300 cc)
    2. History of spontaneous urinary retention
    3. Elderly.
• Phosphodiesterase inhibitors
• Phosphodiesterase type 5 inhibitors (PDE5Is) have been shown to not only improve erectile function, but also are an effective treatment for male LUTS.
• Tadalafil 5 mg daily, due to its longer half-life, is approved for male LUTS.
• Studies have shown improvements in IPSS, storage and voiding symptoms, and quality of life.
• We recommend long-acting PDE5Is as therapy for men with MLUTS/BPH, particularly men with both MLUTS and erectile dysfunction
• Desmopressin
• Nocturnal polyuria often coexists with MLUTS and BPH, but may not respond to typical BPH pharmacotherapies.
• Desmopressin is a synthetic analogue of the anti-diuretic hormone, arginine vasopressin (AVP). Desmopressin reduces total nocturnal voids and increases hours of undisturbed sleep by reducing urine production in men with nocturnal polyuria.
• While the risk of hyponatremia is low in men with normal baseline serum sodium, sodium must be checked at baseline and 4–8 days as well as 30 days after initiation of treatment in (2):
1. All men taking desmopressin melts
2. Men ≥65 years taking 50 μg oral disintegrating tablet
• We recommend desmopressin as a therapeutic option in men with MLUTS/BPH with nocturia as result of nocturnal polyuria
• Phytotherapies
• Plant-based herbal preparations may appeal to some patients. Common formulations include Serenoa repens (saw palmetto), Pygeum africanum (African plum bark), and Urtica dioica (stinging nettle).
• Two ex vivo experiments have demonstrated conflicting results. Pretreatment with S. repens for 3 months before suprapubic prostatectomy demonstrated a decrease in prostatic DHT and an increase in prostatic testosterone concentrations compared with controls, which suggests inhibition of 5α-reductase activity [Campbell’s 11th edition, Chapter 104, p. 2499]
• We do not recommend phytotherapies as standard treatment for MLUTS/BPH

 

• Third-line: Surgery
• Indications for surgery (7):
1. Recurrent or refractory urinary retention
2. Recurrent urinary tract infections (UTIs)
3. Bladder stones
4. Recurrent hematuria
5. Renal dysfunction secondary to BPH
6. Symptom deterioration despite medical therapy
7. Patient preference

• The presence of a bladder diverticulum is not an absolute indication for surgery unless associated with recurrent UTI or progressive bladder dysfunction

UrologySchool.com summary of size considerations:

• TURP: 30-80g
• Plasma button: <60g
• Open simple: >80g
• TUIP: <30g
• Urolift, aquablation: <80g
  • Urolift cannot be done with median lobe, aquablation can
• HOLEP/PVP: not explicitly stated
• Ejaculatory preserving: TUIP, urolift, aquablation

 

• TURP
• Monopolar TURP (M-TURP)
• Standard first-line surgical therapy for men with moderate to severe MLUTS/BPH with prostate volume of 30–80 cc
• Potential complications: bleeding (2–9%), capsule perforation with significant extravasation (2%), TUR syndrome (0.8%), urinary retention (4.5–13%), infection (3–4%; sepsis 1.5%), incontinence (<1%), bladder neck contracture (3–5%), retrograde ejaculation (65%), erectile dysfunction (6.5%), and surgical retreatment (2%/year).
• Bipolar TURP (B-TURP)
• Standard first-line surgical therapy for men with moderate to severe MLUTS/BPH with prostate volume of 30–80 cc; has evolved as an equivalent alternative to the monopolar technique
• Advantages (3):
1. Reduction in the risk of dilutional hyponatremia (TUR syndrome)
2. Improvements in intraoperative visibility
3. May result in shorter catheterization times
• Bipolar plasma kinetic vaporization/plasma button TURP
• An alternative first-line surgical therapy for men with moderate to severe MLUTS/BPH and prostate volume <60 cc

• Open simple prostatectomy
• First-line surgical therapy for men with moderate to severe MLUTS/BPH and prostate volume >80 cc
• Other indications for OSP include (2):
  1. Plans for concurrent bladder procedure, such as diverticulectomy or cystolithotomy
  2. Men who are unable to be placed in dorsal lithotomy position due to severe hip disease
• Laser prostatectomy
• Can be used to treat men on anti-coagulation and those with bleeding dyscrasia
• Holmium laser enucleation of the prostate (HoLEP)
• The procedure requires a steep learning curve (estimated >20–50 cases) often requiring fellowship training.
• We recommend HoLEP as an alternative to TURP or OSP in men with moderate to severe LUTS if performed by a HoLEP-trained surgeon [no size cut-off]
• Photoselective vaporization of the prostate (PVP)
• We recommend PVP as an alternative to TURP in men with moderate to severe LUTS [no size cut-off]
• We suggest Greenlight PVP therapy as an alternate surgical approach in men on anti-coagulation or with a high cardiovascular risk
• Diode laser vaporization of the prostate
• We suggest diode laser vaporization of the prostate as an alternative to TURP in men with moderate to severe LUTS
• We suggest diode laser vaporization of the prostate as an alternate surgical approach in men on antic-oagulation
• Thulium laser
• We suggest Tm:YAG vaporization of the prostate as an alternative to TURP in men with moderate to severe LUTS with prostate volume <60 cc.
• Thulium enucleation may be an alternative to OSP and HoLEP in men with moderate to severe LUTS with prostate volume >80 cc
• Transurethral incision of the prostate (TUIP)
• We recommend TUIP to treat moderate to severe LUTS in men with prostate volume <30 cc without a middle lobe. These patients should experience symptom improvements similar to TURP with a lower incidence of retrograde ejaculation.
• Minimally invasive surgical therapies
• Transurethral microwave therapy (TUMT): an option for elderly patients with significant comorbidities or greater anaesthesia risks as long-term durability is limited
• Transurethral needle ablation (TUNA): should not be offered as a consideration for treatment of BPH/LUTS
• Prostatic stents should only be used as an alternative to catheterization in men unfit for surgery with a functional detrusor for those medically unfit for surgery
• New and emerging therapies
• Prostatic urethral lift (Urolift):
• Provides less effective, but adequate and durable improvements in IPSS and Qmax compared to TURP
• Preserves sexual function, no reported case of retrograde ejaculation.
• May be considered an alternative treatment for men with LUTS interested in preserving ejaculatory function, with prostates <80 cc and no middle lobe
• Rezum system of convective water vapour energy ablation:
• May be considered an alternative treatment for men with LUTS interested in preserving ejaculatory function, with prostates <80 cc, with or without middle lobe
• Image-guided robotic waterjet ablation:
• Offered to men with LUTS interested in preserving ejaculatory function, with prostates <80 cc, with or without middle lobe
• Temporary implantable nitinol device (iTIND): We recommend that iTIND (a mechanical, stent-like device designed to remodel the bladder neck and the prostatic urethra through pressure necrosis) should not be offered at this time for the treatment of LUTS due to BPH
• Prostatic artery embolization (PAE): should not be offered at this time for the treatment of LUTS due to BPH

See Figure 3 from CUA MLUTS/BPH Guidelines

Special situations

• Patients with symptomatic prostatic enlargement in the absence of significant bother may be offered a 5-ARI inhibitor to prevent progression of the disease
• Men with acute urinary retention due to BPH should be offered a trial of voiding 2-7 days after catheterization while receiving an alpha-blocker.
• There is no effective treatment for detrusor underactivity, defined as a contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span. In primary detrusor underactivity treatment approach should be to facilitate bladder emptying, identify agents that can decrease bladder contractility, or increase urethral resistance. Behavioural modification, including scheduled voiding and or double voiding, clean intermittent self-catheterization, or indwelling catheters, are optional strategies. The data suggests that detrusor underactivity is not necessarily a contraindication for TURP.
• In men with BPH-related bleeding, a complete assessment, including history and physical examination, urinalysis (routine microscopy, culture & sensitivity, cytology), upper tract radiologic assessment and cystoscopy, is necessary to exclude other sources of bleeding. If the source of bleeding if felt to be from BPH, a trial with a 5-ARI is appropriate.
• The BPH patient with an elevated serum PSA and negative prostate biopsy may be counselled on the proven benefits of using a 5-ARI for prostate cancer risk reduction.
  • While both PCPT and REDUCE were associated with similar reductions in the overall rate of prostate cancer, there was one observed difference between the trials.
    • In the PCPT (Prostate Cancer Prevention Trial) study, a slight increase in the risk of high grade (Gleason ≥7) prostate cancer was observed among the finasteride cohort compared to the placebo group.
      • Most experts believe this phenomenon was due to an artifact of prostate glandular cytoreduction, induced by the 5-ARI, although some controversy exists.
    • In the REDUCE (Reduction by Dutasteride of Prostate Cancer Events) trial, the number of patients found to have Gleason ≥7 prostate cancer was not significantly different between groups, however, increased risk of Gleason 8-10 cancers was found during years 3 and 4 in dutasteride arm. Therefore, the patient must be aware of the possible low absolute increased risk (0.5–0.7%) in incidence of high-grade (Gleason 8–10) cancer with 5ARI use.
  • Patients who experience a rising PSA after 6-12 months of 5-ARI therapy should be assessed for the possibility of high-grade prostate cancer.

Questions

1. What is the mandatory work-up of a male patient with LUTS? Recommended? Optional?
2. What are the domains of the IPSS score?
3. What is the IPSS score for mild, moderate, severe LUTS?
4. What are risk factors for BPH progression?
5. Which lifestyle recommendations are described to improve LUTS?
6. What are potential side effects of alpha-blockers? 5-ARIs?
7. What prostate size have 5-ARIs been shown to be of benefit?
8. When should desmopressin be considered in the treatment of BPH? Which patients should have sodium testing and what is the timing?
9. What are the indications for surgical intervention of BPH?
10. List complications of TURP?
11. What are the standard first-line surgical therapies for BPH?
12. What treatments are r prostates that are 30-80g?
13. What are potential benefits of bipolar over monopolar TURP?
14. What are the indications for open simple prostatectomy?
15. What patient is an ideal candidate for transurethral incision of the prostate?
16. In which patients should a Uro-lift be considered? Rezum?

 

Answers

1. What is the mandatory work-up of a male patient with LUTS? Recommended? Optional?
   • Mandatory: H+P, urinalysis +/- culture
   • Recommended: symptom questionnaire, PSA
   • Optional: PVR, uroflow, voiding diary, cytology, sexual function questionnaire, serum creatinine
2. What are the domains of the IPSS score?
   • FUNWISE Frequency, urgency, nocturia, weak stream, intermittency, straining, emptying + QOL
3. What is the IPSS score for mild, moderate, severe LUTS?
   • Mild: 1-7
   • Moderate: 8-18
   • Severe: 19-35
4. What are risk factors for BPH progression?
1. Age
2. PSA
3. LUTS severity
4. Prostate volume
5. Which lifestyle recommendations are described to improve LUTS?
1. Fluid restriction particularly prior to bedtime
2. Avoidance of caffeinated beverages, spicy foods
3. Avoidance/monitoring of some drugs (e.g., diuretics, decongestants, antihistamines, antidepressants)
4. Timed or organized voiding (bladder retraining)
5. Pelvic floor exercises
6. Avoidance or treatment of constipation
6. What are potential side effects of alpha-blockers? 5-ARIs?
   • Alpha-blockers (5): retrograde ejaculation, dizziness, headache, nasal congestion, priapism
   • 5-ARIs (4): erectile dysfunction, decreased libido, ejaculatory dysfunction, gynecomastia
7. What prostate size have 5-ARIs been shown to be of benefit?
   • >30g
8. When should desmopressin be considered in the treatment of BPH? Which patients should have sodium testing and what is the timing?
   • In men with nocturia secondary to nocturnal polyuria
   • All men taking melts and men age ≥ 65 taking disintegrating tablets
9. What are the indications for surgical intervention of BPH?
1. Recurrent or refractory urinary retention
2. Recurrent urinary tract infections (UTIs)
3. Bladder stones
4. Recurrent hematuria
5. Renal dysfunction secondary to BPH
6. Symptom deterioration despite medical therapy
7. Patient preference
• The presence of a bladder diverticulum is not an absolute indication for surgery unless associated with recurrent UTI or progressive bladder dysfunction
10. List complications of TURP?
    • Intra-operative: bleeding, perforation, TUR syndrome, infection,
    • Early post-operative: urinary retention, retrograde ejaculation, incontinence
    • Late post-operative: failure to improve symptoms, bladder neck contracture, urethral stricture
11. What are the standard first-line surgical therapies for BPH?
1. Monopolar TURP
2. Bipolar TURP
12. What treatments are r prostates that are 30-80g?
1. Monopolar TURP
2. Bipolar TURP
3. Greenlight PVP
4. HoLEP
5. BPKVP
6. Thulium laser
7. Diode laser
8. Urolift
9. Rezum
10. TUMT
11. Aquablation
13. What are potential benefits of bipolar over monopolar TURP?
1. Reduction in the risk of dilutional hyponatremia (TUR syndrome)
2. Improvements in intraoperative visibility
3. May result in shorter catheterization times
14. What are the indications for open simple prostatectomy?
1. Moderate to severe LUTS with prostate size > 80
2. Undergoing concomitant bladder procedure (e.g. diverticulectomy)
3. Unable to be put in dorsal lithotomy position (e.g. severe hip disease)
15. What patient is an ideal candidate for transurethral incision of the prostate?
• Prostate volume <30 cc without a middle lobe and interested in preserving ejaculatory dysfunction
16. In which patients should a Uro-lift be considered? Rezum?

• Uro-lift: Men interested in preserving ejaculatory function with prostate <80 and no median lobe
• Rezum: Men interested in preserving ejaculatory function with prostate <80 with or without