Editing CUA: Male LUTS & BPH (2018) (section)

== 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.