BPH Flashcards
In the initial evaluation of patients with bothersome LUTS possibly attributed to BPH, clinicians SHOULD obtain:
GUIDELINE STATEMENT 1
Medical history (sexual hx, meds, overall fitness and health)
Physical exam
IPSS/AUA SS (symptom burden)
UA (bacteria, rbc, wbc, glucose, protein)
Options:
PVR, uroflow, pressure flow studies
What first options for management of LUTS SHOULD patients be counselled?
GUIDELINE STATEMENT 2
behavioral/lifestyle modifications (limit fluids qHS, with travel, caffeine, ETOH, spicy foods, chocolate, avoid constipation, increase activity, weight loss, kegels, timed voiding, double voiding, PFME +/- biofeedback)
medical therapy if additional tx necessary
referral for surgical evaluation (if seen by PCP)
After initiating treatment, when SHOULD providers assess response and how should patients be evaluated?
GUIDELINE STATEMENT 3
4-12 weeks after
(alpha blockers, beta 3 agonists, PDE5I and AC, shorter acting → as early as 4 weeks, longer acting 5-ARIs 3-6 mo)
IPSS/AUA SS
Uroflow and PVR
Consider Global Subjective Assessment
Patients with bothersome LUTS/BPH who elect initial medical management and do not have symptom improvement and/or intolerable side effects SHOULD:
GUIDELINE STATEMENT 4
undergo further evaluation and change medical management or proceed to surgery
consider UDS to confirm BOO vs. DO
trial additional medication classes
Prior to intervention for LUTS/BPH what SHOULD clinicians consider assessment of:
GUIDELINE STATEMENT 5
prostate size and shape via TRUS or abdominal US, cysto, cross sectional imaging (MRI/CT) if studies available (w/in 12 mo preferred)
volume: ellipsoid volume (height x length x width x 0.523)
*DRE and PSA unreliable in estimating size
Prior to sx intervention for BPH, what office based test SHOULD be done if it has not been done prior?
GUIDELINE STATEMENT 6
PVR
“large” PVR > 300 is worth monitoring, may warrant UDS vs. surgery
*does not seem to be a strong predictor of AUR
GUIDELINE STATEMENT 7
Uroflow
*must void 150 cc, no valsalva, characterize voiding dysfunction
Prior to surgical intervention for BPH/LUTs, what can be CONSIDERED if diagnostic uncertainty exists?
GUIDELINE STATEMENT 8
Pressure flow studies (UDS)
contractility, Qmax, peak voiding pressures, BOO
When considering minimally invasive sx for LUTS/BPH, what SHOULD clinicians counsel patients is possible in regards to outcomes?
GUIDELINE STATEMENT
treatment failure and need for secondary treatments
objective failure (urinary retention, reduction of Qmax, increased PVR, infection)
subjective failure (worsening IPSS, increase in duration of f/up or tx)
When treating BPH medically which class of medications would you start with and name all the medications in that class? What is the choice of medication bae on?
GUIDELINE STATEMENT 10
alpha blockers for bothersome, moderate-severe LUTS/BPH
alfuzosin, doxazosin, silodosin, tamsulosin, terazosin
GUIDELINE STATEMENT 11
choice of alpha blocker should be based on age, comorbidities, and different adverse effects (EjD, BP)
Which alpha blockers have the highest risk of orthostatic hypotension?
terazosin and doxazosin
tamsulosin best for BP, followed by alfuzosin and silodosin
What are alpha blockers with lowest risk of EjD?
doxazosin or terazosin
alfuzosin
*due to paralysis of smooth muscles in wall of prostatic ducts → anejaculation
What other surgical procedures warrant caution or further consideration in regards to starting alpha blockers?
GUIDELINE STATEMENT 12
with planned cataract surgery there is risk of intraoperative floppy iris syndrome
should be discussed with optho or defer initiation
discontinue 4-7 days prior to cataract, but does not completely eliminate IFIS
When is 5-ARI monotherapy appropriate for treatment of LUTS/BPH? What is the mechanism of action? what types are utilize?
GUIDELINE STATEMENT 13
prostatic enlargement > 30 cc on imaging, a PSA > 1.5, or palpable enlargement on DRE
Finasteride 5 mg (isoenzyme II only)
Dutasteride 0.5 mg (isoenzyme I and II)
*act via inhibition of alpha reductase (testosterone → DHT) leading to less available DHT → reduction in overall androgenic growth stimulus → atrophy and shrinkage (15-25% in 6 mo)
Reduction in prevalence of prostate cancer (RRR 25%, but more high grade prostate cancer dx)
What is meant by combination therapy? Utilization of which medication as part of this regimen can reduce the risk of urinary retention and need for surgery?
MTOPS trial
GUIDELINE STATEMENT 14
5ARIs alone or in combo with alpha blockers are recommended as tx option to prevent progression of LUTS/PGH and/or reduce risk of urinary retention and need for future prostate surgery
GUIDELINE STATEMENT 18
5-ARI in combo with alpha blockers should be offered as treatment only when prostate volume > 30 cc, PSA > 1.5, or palpable enlargement on DRE
What should clinicians counsel as adverse effects of 5-ARIs?
GUIDELINE STATEMENT 15
sexual side effects, physical side effects, low risk of CaP
MTOPS→ decline in sexual and ejaculatory function, decreased libido
Gynecomastia, dementia, depression, DMII (2x risk), post finasteride syndrome
What other indication can 5 ARIs be utilized for?
GUIDELINE STATEMENT 16
reduce intraoperative bleeding in peri- or postoperative need for blood txf after TURP or surgical intervention for BPH
Besides alpha blockers or 5ARIs what is an additional daily therapy for BPH/LUTs?
GUIDELINE STATEMENT 17
5 mg tadalafil should be discussed as a treatment option irrespective of comorbid ED
*can offer similar results seen with tamsulosin but does not improve UDS parameters
When are anticholinergics/beta-3 agonists indicated in treatment of BPH/LUTS?
GUIDELINE STATEMENT 19
alone or in combo with alpha blockers, may be offered as option with moderate-severe predominant storage LUTS
*AUR low in selected patients
PVR obtained, precautions used (gastric emptying, GI motility issues, narrow angle glaucoma, dementia)
GUIDELINE STATEMENT 20
beta-3-agonists in combo with alpha blocker may use used as treatment option in patients with moderate-severe predominant storage LUTS
Which combination therapy should not be prescribed for treatment of LUTS/BPH?
GUIDELINE STATEMENT 21
5 mg tadalafil and alpha blockers, offers no advantages in symptom improvement over either agent alone
no advantage of tadalafil and finasteride either
What are important elements to consider for TOV and what should patients be conselled?
GUIDELINE STATEMENT 22
prescribe alpha blockers prior to voiding trial for AUR
GUIDELINE STATEMENT 23
newly treated for AUR with alpha blockers, complete at least 3 days of tx before TOV
GUIDELINE STATEMENT 24
patients who pass TOV for AUR from BPH are at higher risk of recurrent AUR
What are indications to proceed to surgery for BPH?
GUIDELINE STATEMENT 25
renal insufficiency secondary to BPH
refractory urinary retention due to BPH
recurrent UTIs
recurrent bladder stones or gross hematuria due to BPH
with LUTS/BPH refractory or unwilling to use other therapies
How do you manage a bladder diverticulum in the presence of BPH?
GUIDELINE STATEMENT 26
should not perform surgery solely based on presence of asx bladder diverticulum; however, evaluation for BOO should be considered
(indications for surgery are same for BPH in general, treat BOO as indicated)
Surgical treatment options for BPH
List sx treatment options for BPH and recommenations:
GUIDELINE STATEMENT 27/28
TURP, monopolar or bipolar depending on expertise
GUIDELINE STATEMENT 29
open, lap, robotic assisted prostatectomy for large to very large prostates
GUIDELINE STATEMENT 30
TUIP, prostates < 30 cc, lower rate of RE or blood txf
GUIDELINE STATEMENT 31
Bipolar TUVP (rollerball, vaportrode, loop, button) → improved blood loss
GUIDELINE STATEMENT 32
PVP should be offered using 120 W or 180 W platforms (anticoagulation)
GUIDELINE STATEMENT 33/34
PUL considered volumes 30-80 with absence of obstructing median lobe as an option for patients that desire preservation of erectile and ejaculatory function
GUIDELINE STATEMENT 35
TUMT (transferring energy to tissue creating heat, special cooling cath)
GUIDELINE STATMENT 36/37
WVTT (Rezum–water vapor thermal therapy) for volumes 30-80 cc as an option for patients that desire preservation of erectile and ejaculatory function
GUIDELINE STATMENT 38
TUNA IS NOT RECOMMENDED
GUIDELINE STATEMENT 39
HoLEP or ThuLEP considered depending on expertise and prostate size (less txf, AC)
GUIDELINE STATEMENT 40
Robotic water jet (RWT) prostates 30-80 cc (TRUS map and transurethral waterjet robotic hand-piece)
What is the role for PAE in BPH?
GUIDELINE 41
not supported for routine treatment, benefit over risk remains unclear, not recommended outside clinical trials
Hematuria can be deemed due to BPH when:
GUIDELINE STATEMENT 42
all other causes have been excluded, 5ARIs may be appropriate and effective tx alternative for refractory hematuria due to BPH
*suppression of vascular endothelial growth factor (VEGF), decreased angiogenesis and bleeding
*role of PAE in mgmt. of refractory hematuria evolving
What surgical options should be utilized for patients who are at higher risk of bleeding?
GUIDELINE STATEMENT 43
HoLEP, PVP, ThuLEP
Important questions to ask for BPH patient history?
IPSS/AUA SS
SHIM
symptom duration
bother
frequency of sxs
frequency of incontinence
how many times does patient void daily
weakened stream, stranguria, hesitancy, intermittency, sensation of incomplete emptying, nocturnal enuresis
volume of fluid intake/caffeine
hematuria, dysuria, hx STD or UTIs
urgency
leakage with activity or cough
Important aspects of PE for BPH?
cognition, neuro
extremities for edema and pulses
general appearance (obesity)
abdomen (bladder distention, flank)
penis (curvature, meatus)
testis
perineum (sensation)
anal tone
DRE (prostate)
DDX of worsening LUTS in men?
Neurologic (MS, SCI, CVA, Parkinson’s)
BNO
CIS, bladder cancer
UTI
Urinary retention
Urethra stricture
Polydipsia
OAB
Nocturnal polyuria
How do you monitor post obstructive diuresis?
Insert foley (urinary retention)
Frequent orthostatic (BP/HR) vitals to assess for conversion to POD
Ask patient to drink fluids to thirst
Monitor UOP
Intermittent serum chemistries to assess recovery of renal function
Definition of post obstructive diuresis? tx?
a polyuric and natriuretic state after relief of obstruction
clinical dx UOP > 200 mL/hr for 2 h or > 3L in 24 h
physiologic diuresis usually self limited
strict monitoring of UOP, weight, electrolytes (mag, phosphate, urea, creatinine) q 4-q12h
collect urine for urinary sodium, potassium, osmo to determine type, spot Na > 40 mEq/L imply renal tubular injury and can lead to pathologic POD
drink to taste (avoid excess)
if unable to drink give D5 ½ NS maintenance plus replace ½ cc per cc with D5 ½ NS
Can get US in 48h to confirm resolution of hydro
If remove foley, need to teach CIC
Consider UDS and sx
Can trial medical therapy with backup of CIC
How do you manage post TUR syndrome?
Abort surgery
place large bore foley overfilling balloon to compress bladder neck with traction (if unable to finish surgery or bleeding)
administer Lasix 20 mg to induce free water clearance
Perform blood gas requesting serum Na to asses hyponatremia
Transfer to ICU for continuous vitals and seizure precautions
Calculate free water excess in case hypertonic saline needed
What are urinary storage symptoms?
nocturia
SUI
UUI
frequency
urgency
risks of transurethral prostate surgery?
urethral stricture
infection
bleeding/txfn
long term prostate regrowth and repeat procedure
ED
ejaculatory dysfunction
injury to adjacent structures
bladder neck contracture
IPSS
What is initial tx for LUTS s/p TURP?
UA and UCX
if no UTI → observation (some irritative sxs and UUI atributoed to DO secondary to prostatic obstuction, healthing resected fossa, and irritate urthera post instrumentation)
Uusally 4-6 weeks, improves tover 12 weeks
stress reduction, timed voiding, fuluid restriction, dietary adjustments
What is BPH?
BPH is a histologic diagnosis that refers to the proliferation of smooth muscle and epithelial cells within the prostatic transition zone.
What is included in the initial evaluation of patients presenting with LUTS?
In the initial evaluation of patients presenting with LUTS, a medical history should be obtained, a physical examination should be conducted, the International Prostate Symptom Score (IPSS) should be utilized, and a urinalysis should be performed.
What are some optional studies that may be used to confirm the diagnosis of BPH?
Optional studies that may be used to confirm the diagnosis or evaluate the presence and severity of BPH include PVR, uroflowmetry, and pressure flow studies.
What is the recommended time interval for follow-up evaluation after initiation of treatment for bothersome LUTS/BPH?
Patients should be evaluated by their providers 4-12 weeks after initiating treatment, provided adverse events do not require earlier consultation, to assess response to therapy.
What tests are recommended during follow-up evaluation?
Revaluation should include the IPSS, and further evaluation may include a post-void residual (PVR) and uroflowmetry.
What is the significance of changes in Qmax during follow-up evaluation?
There are no thresholds in the literature for monitoring changes in Qmax to help guide therapy, but on average, an improvement between 1 and 5 mL/s may be expected, while some patients may experience no changes or even a minor deterioration.
What is the significance of changes in IPSS/QoL during follow-up evaluation?
There are no thresholds in the literature for monitoring changes in the IPSS/QoL to help guide therapy, but directional changes can be used as a springboard to a meaningful discussion of patients’ expectations of symptom improvement, perceived response to treatment, and goals of treatment.
What is the Global Subjective Assessment (GSA) used for during follow-up evaluation?
GSA is used to assess subjective responses to therapy and is correlated to the changes in the IPSS score at the same follow-up visit. The administration of the IPSS is recommended at each time point of follow-up to enable a conversation about expectations and satisfaction and may lead to changes in treatment. Utilizing a GSA could also be considered at follow-up evaluation to further direct the conversation.
Why is it important to assess prostate size and shape before intervention for LUTS/BPH?
Assessing prostate size and shape is important because it plays a crucial role in the decision-making process for the treatment of LUTS/BPH. Prostate size and morphology can predict poor outcomes from watchful waiting and some medical therapies. Some therapeutic alternatives are only indicated for prostates of specific sizes, and larger prostates may require different interventions. DRE and serum PSA are unreliable in estimating prostate size, so it is recommended to have prostate imaging prior to surgical interventions.
What types of imaging can be used for prostate size and shape assessment?
Prostate size and shape can be assessed by transrectal or abdominal ultrasonography, cystoscopy, or cross-sectional imaging such as CT or MRI.
How accurate can older imaging be in estimating current prostate size?
Older imaging can still give a reasonably accurate estimate of current prostate size, but it is preferred to have imaging obtained within the past 12 months. Prostate growth rates are 1.6% per year on average.
How is prostate size calculated using transrectal or transabdominal ultrasound or cross-sectional imaging?
Prostate size is calculated using the volume formula for an ellipsoid body, either ([height x length x width] x pi/6) or ([height x length x width] x 0.523). For ultrasound measurements, it does not matter if the height is measured in the axial or midsagittal image.
What should be done if the initial medical management does not lead to symptomatic improvement?
If initial medical management does not lead to symptomatic improvement, referral to a specialist for additional workup and treatment options is recommended. The reason for medication failure and etiology of LUTS should be considered by performing studies such as urodynamics. The specialist can then determine the best course of action, which may include a change in medical management or surgical intervention.
What is considered a “large” PVR?
A “large” PVR is considered to be greater than 300 mL.
What is the relationship between PVR and AUR?
While a clinically useful test that may drive management choices, PVR does not seem to be a strong predictor of AUR.
What is the minimum threshold voided volume for adequate interpretation of uroflowmetry?
The minimum threshold voided volume for adequate interpretation of uroflowmetry is 150cc.
What other information is obtained from uroflowmetry besides the flow rate?
In addition to the flow rate, the shape of the curve and the duration of voiding provide useful information from uroflowmetry.
How can the results of uroflowmetry be useful in determining the impact of therapy on improving obstruction?
The results of uroflowmetry can be useful in determining the impact of therapy on improving obstruction by comparing pre- and post-operative flow rates
What is uroflowmetry and why is it important to consider prior to intervention for LUTS/BPH?
Uroflowmetry is a screening tool used to measure the flow rate of urine during urination. It is important to consider prior to intervention for LUTS/BPH because it helps to characterize the voiding dysfunction and is useful in counseling patients regarding surgical outcomes and expectations.
What is a pressure flow study?
A pressure flow study is a type of urodynamic study that is used to determine the presence of bladder outlet obstruction (BOO) by measuring the voiding pressures and maximum urinary flow rate.
Why is a pressure flow study considered the most complete means to determine the presence of BOO?
A pressure flow study is considered the most complete means to determine the presence of BOO because it is the only test that can document detrusor contractility or lack thereof.
Why is a pressure flow study advised for patients with catheter-dependent urinary retention?
A pressure flow study is advised for patients with catheter-dependent urinary retention because it can help differentiate the underlying conditions related to their LUTS.
Can pressure flow studies inaccurately indicate a lack of detrusor contractility?
Yes, there are patients with conditions such as bladder diverticulum in whom pressure flow studies inaccurately indicate a lack of detrusor contractility.
What was the result of the 29 RCTs reviewed by Taylor and Jaffe?
Taylor and Jaffe reviewed 29 RCTs and found that nearly 15% of TURP patients required a secondary procedure after 8 years.
What is the conclusion about TUVP based on the six RCTs with a follow-up of less than or equal to 1 year?
The conclusion about TUVP based on the six RCTs with a follow-up of less than or equal to 1 year was that TUVP showed similar need for reoperation, but no conclusions can be made regarding long-term efficacy and/or retreatment rates due to the short follow-up of the studies and the lack of reporting of medication retreatment in either arms.
What was the result of reoperation due to symptom recurrence in the L.I.F.T. study at 5 years?
Reoperation due to symptom recurrence at 5 years was reported for 19 of 140 participants in the L.I.F.T. study, with 6 receiving additional PUL implants and 13 undergoing TURP or laser procedures.
Was there a difference in reoperation due to symptom recurrence between PUL and TURP in the BPH6 study?
There was no significant difference in reoperation due to symptom recurrence between PUL and TURP in the BPH6 study over the 2-year study period.
How many patients in the PUL arm of the BPH6 study underwent retreatment for LUTS during the 2-year follow-up period?
Six patients (13.6%) in the PUL arm of the BPH6 study underwent retreatment for LUTS during the 2-year follow-up period.
What were the results of the trials that compared TUMT to TURP or control?
Four trials (n=499) compared TUMT to TURP or control. The mean baseline IPSS was 21 (range 20 to 21), and the mean prostate volume was 56mL (range 50 to 69mL). The follow-up periods ranged from six months to five years. The results showed that reoperation was significantly higher with TUMT (9.9%) compared to TURP (2.3%). The medication retreatment in either arm of this study was not reported.
What was the retreatment rate due to LUTS at the primary double-blind period of three months in the study by McVary et al.?
At 4 years follow up, the reported retreatment rate had increased to 9.6% in the study by McVary et al.
What were the results of the studies comparing HoLEP to TURP in terms of reoperation due to recurrence of symptoms?
Pooled analysis of 4 studies comparing HoLEP to TURP showed no differences in reoperation due to recurrence of symptoms (RR: 0.42; 95%CI: 0.07, 2.48).
What was the outcome of the Gilling study at 36 months follow-up?
At 36 months follow-up, one participant in the TURP group (1.5%) and 5 participants in the RWT group (4.3%) required surgical retreatment for BPH.
What are the alpha blockers recommended for the treatment of LUTS/BPH?
Clinicians should offer one of the following alpha blockers as a treatment option for patients with bothersome, moderate to severe LUTS/BPH: alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin.
How effective are alpha blockers for the treatment of LUTS and BPH?
Alpha blockers have been demonstrated to be effective for the treatment of LUTS and BPH through multiple phase III RCTs, Phase IV studies, systematic reviews, and meta-analyses. They are all relatively equally effective in terms of IPSS improvement, with an expected range of improvement of 5-8 points compared to an expected effect of placebo from 2-4 points.
Is there any difference in efficacy between different alpha blockers?
There is no difference in efficacy between different alpha blockers. Studies have attempted to identify subgroups of patients who may respond better to one alpha blocker or another, but these data have demonstrated equal efficacy across all alpha blockers.
What should be done if a patient fails to have sufficient improvement with the first alpha blocker?
If a patient fails to have sufficient improvement with the first alpha blocker, it is not recommended to switch between different alpha blockers as it is unlikely to improve the response. Providers are encouraged to reassess and discuss alternative treatment strategies or to further investigate the phenotype of the patient. However, changing from one alpha blocker to another on the basis of a side effect is worthwhile.
How does the choice of alpha blocker affect the occurrence of ejaculatory dysfunction?
The choice of alpha blocker affects the occurrence of ejaculatory dysfunction. EjD is more prevalent with tamsulosin and silodosin than with other alpha blockers.
What is the difference between retrograde ejaculation and anejaculation?
Retrograde ejaculation is a phenomenon commonly found after TURP and surgeries affecting the anatomy of the bladder neck and prostate. Anejaculation is a phenomenon that results in a decreased ejaculate volume and is associated with selective alpha 1a blockers.
