Campbell Evaluation and Nonsurgical Management of BPH Flashcards
The main goal of the baseline interview
of any patient is ____.
to identify potential causes of LUTS so as to
further address the diagnostic and therapeutic decision-making process with a more patient-tailored approach
The DRE has a double aim: (2)
Obtain baseline estimation of prostate volume.
Exclude palpable nodules or any increased consistency, that may signal the presence of PCA.
** The sensitivity of DRE in detecting PCa is low, with historical
series showing PCa detection rates on biopsy as low as 40% to
50% in the era before prostate-specific antigen (PSA) testing among
patients with positive DRE findings
International clinical guidelines advise that _____ should be used during the basic evaluation of
patients with prevalent storage LUTS or nocturia
FVCs (or their derived forms)
*** Frequency-volume charts (FVCs), recording the voided volume
and the time of each micturition during day and night hours for
24 hours
VS.
*** Bladder diaries, recording the time of micturition, voided volume,
and additional information such as fluid intake, incontinence
episodes, degree of incontinence, pad usage, and degree of urgency
The use of a _____ is suggested in all patients complaining of LUTS
as a part of the baseline evaluation
dipstick test and/or the microscopic evaluation of urine samples
_____ should always be requested in men with severe
storage symptoms and dysuria, especially if they have a smoking
history.
Urine cytology
The value of PSA testing among patients presenting for LUTS is
multiple: _____ (3)
assess the risk and eventually rule out the presence of
PCa;
estimate PV;
and predict BPH-related outcomes.
Current international clinical guidelines suggest measurement of PSA if
_____, excluding, for instance, those ______.
a diagnosis of PCa will change LUTS management,
men with a life expectancy of less than 10 years
PSA level at which there is a 65-70% chance of detection of prostate volume > 40 mL at a specific age.
PSA level at which there is a 65-70% chance of detection of prostate volume > 40 mL at a specific age.
- 6 ng/mL = 50s
- 0 ng/mL = 60s
- 3 ng/mL = 70s
Caution should be paid in patients treated with 5α-reductase inhibitors (5ARIs), given that serum PSA level is reduced by ____
40% to 50% after 12 months of treatment
TRUE or FALSE
The assessment of renal function based on serum creatinine level
or estimated glomerular filtration rate is not routinely suggested in patients with LUTS.
TRUE
The assessment of renal function based on serum creatinine level
or estimated glomerular filtration rate is NOT routinely suggested
in patients with LUTS.
As a whole, AUA guidelines no longer recommend a routine renal function assessment but EAU guidelines suggest assessment of serum creatinine level if renal impairment is suspected on the basis of medical history or when surgical treatment is considered.
PVR volume is defined as _____ . Currently, there is no standardized
definition for a normal PVR volume.
In clinical practice, a PVR volume of ____ is usually considered nonsignificant, whereas PVR volume ____ could be regarded as important.
the volume (mL) of urine left in the bladder at the end of micturition
less than 30 mL (nonsignificant)
persistently greater than 50 mL (important)
ICS Urodynamics Committee for correct assessment of PVR Volume:
• The interval between voiding and PVR volume measurement
should be of short duration.
• Although transurethral catheterization is considered the gold
standard to assess PVR volume, it could be associated with patient
discomfort and the risk for UTIs and urinary tract trauma.
• The ultrasound bladder volume measurement should be used
to assess PVR volume and can be performed with either a
real-time transabdominal ultrasound scanner or a portable
bladder scanner.
The presence of an abnormal PVR volume is [HIGHLY or NOT HIGHLY] correlated with BOO.
not highly
Indeed, an abnormal PVR volume could be the consequence of either BOO or DUA. In this context, the diagnostic accuracy of PVR volume measurement has a positive predictive value of 63% and a negative predictive value of 52% to detect BOO
PVR volume assessment is suggested both during _____.
Men with significant PVR volume should be _____.
basic workup and during the follow-up of patients with LUTS.
monitored closely if they elect to have nonsurgical therapy
Uroflow measurement: _____
The main parameters provided by uroflowmetry: (3)
Electronic recording of the free urinary flow rate throughout the course of micturition.
Qmax (or peak urinary flow rate [PFR]): inaccurate if the voided volume is less than 125 to 150 mL
Voided volume
Flow pattern
*** Average flow rate is considered less accurate than Qmax to detect
BOO
*** There is substantial within-subject variation in terms of uroflowmetry
results among measurements taken either on the same
day or on consecutive days
According to expert opinion, a PFR cutoff of _____ could be used to define outlet obstruction in clinical practice.
15 mL/s
*** a PFR of less than 15 mL/s does not differentiate between obstruction and bladder decompensation.
International clinical guidelines consider uroflowmetry as an _____ test in the assessment of patients with LUTS, although its use is recommended _____.
OPTIONAL
before any active treatment
The invasive urodynamic test is the gold standard for the assessment of LUTS pathophysiology and it is used to identify _______.
Two distinct evaluations investigating the storage
and voiding phase of micturition: _____ and ______.
DO, DUA, low bladder compliance, and BOO.
the filling cystometry and the pressure-flow study (PFS).
videourodynamics refers to the use of ______.
This test allows one to obtain ______.
synchronous radiographic imaging and filling the bladder with contrast medium while cystometry and a PFS are performed.
additional anatomic information by showing the presence of eventual alteration of the bladder profile (diverticula, trabeculation), of vesicoureteral reflux, or of alterations of the pelvic floor activity.
** No clear recommendation is currently provided regarding the use
of videourodynamics
Cystometry allows the assessment of the _____.
It is characterized by _____
storage phase.
a continuous fluid filling of the bladder through a transurethral catheter, with a concomitant measurement of intravesical and abdominal pressure and the display of the detrusor pressure
Cystometry: In patients with LUTS suggestive of BOO, the main goal of this test ____.
is the detection of involuntary detrusor contractions, which may identify DO.
*** The diagnosis of DO could be useful to identify patients who
may benefit from the use of anticholinergic drugs either alone or
in combination with other treatments.
PFS allows assessment of the ____.
It is defined as the measurement of the ______ while
uroflowmetry is performed with a transurethral catheter in place
The joint evaluation of detrusor pressure and flow
rate allows the diagnosis of either _____ or _____.
BOO (characterized by impaired flow rate along with an increased detrusor pressure)
or
DUA
(characterized by the impairment of both flow rate and detrusor
pressure).
As invasive diagnostic modalities, both the European and the American guideline panels do NOT routinely suggest the use of urodynamic tests to assess men with LUTS.
However, PFS is suggested before invasive treatments in some specific scenarios:
• Patients with previously unsuccessful invasive treatments for
LUTS
• Patients who cannot void more than 150 mL
• Patients with PVR volume greater than 300 mL
• Patients older than 80 years of age with predominantly voiding
LUTS
• Patients younger than 50 years of age with predominantly
voiding LUTS
ALSO, AUA: PFS may be performed in patients with a Qmax greater than 10 mL/s before
surgical treatment is considered
TRUE or FALSE
The routine assessment of the upper tract with ultrasonography is NOT recommended in patients with LUTS.
TRUE
** In a population of 6102 patients evaluated in 25 studies by intravenous urography
before prostate surgery, only 7.6% were found to have hydronephrosis.
*** imaging assessment of the upper tract is currently suggested for patients with LUTS
combined with an elevated serum creatinine level or large PVR volumes.
patients with a history of hematuria, UTI, urolithiasis, or prior urinary tract surgery should also be assessed with abdominal ultrasonography
Candidates for treatment with 5ARIs should be evaluated for ____.
PV, as treatment outcomes have been related to the baseline gland volume
*** The PV estimated by TRUS imaging was a predictor of BPH progression and invasive treatment in the MTOPS trial
*** Similarly, data from the placebo arm of the ALTESS showed that men with a PV greater than 49 mL had a 3.2% risk for AUR compared with those with a PV of 49 mL or less
Ultrasound-based estimation of PV (either suprapubic or TR) should be routinely performed before _____.
any BPH surgery so as to help the physician in choosing the most appropriate technique
** Moreover, the detection of a third prostate lobe protruding into the bladder could guide the
choice of treatment in patients scheduled for minimally invasive approaches
Intravesical prostatic protrusion (IPP) is defined as _____, can be assessed by suprapubic ultrasound imaging in the ____.
Should be estimated with a volume of ____ of urine in the bladder.
In a cohort of 2115 men with LUTS, a high ______ was associated with a higher
probability of ____.
the distance from the tip of the protruding prostate to the base at the circumference of the bladder.
sagittal plane
100 to 200 mL
IPP grade (>10 mm)
medical treatment over time
TRUE or FALSE
There is currently no clear recommendation for using IPP as a noninvasive alternative to PFS to diagnose BOO.
TRUE
Cystourethroscopy can provide information regarding the ____.
However, cystourethroscopy is neither useful for the diagnosis of BOO nor to determine
the need for treatment.
Clinical guidelines suggest the use of cystourethroscopy in: ______
morphology of the prostate and bladder neck, and the detection of detrusor trabeculation at the level of the bladder wall or the presence of diverticula.
the case of reported gross hematuria,
history of bladder cancer,
history of recurrent UTIs or urethral injury (to rule out urethral stenosis),
or in the case of previous surgery of the prostate or urethra.
WW is based on ____.
If patients choose WW as the preferred management, they
should be: _____
reassurance and education of the patient, lifestyle interventions, and periodic monitoring of the disease.
followed up yearly to detect any progression in terms of symptoms or the occurrence of complications, which should prompt a more aggressive treatment approach
** Data from longitudinal community-based studies show that unfavorable outcomes such as AUR and BPH-related surgery are relatively uncommon throughout the natural history of BPH patients, reporting a cumulative incidence of 1% to 2.7% for AUR and 3% for surgery
** recent 15-year longitudinal study, 50% of included patients showed stable symptom scores over the time frame investigated
Lifestyle and Dietary Modifications: Education and reassurance: (3)
• Discuss the causes of LUTS, including normal prostate and
bladder function.
• Discuss the natural history of BPH and LUTS, including the
expected future symptoms.
• Reassure the patient that no evidence of detectable PCa has
been found.
Lifestyle and Dietary Modifications: Fluid Management (4)
Fluid Management
• Advise a daily fluid intake of 1500 to 2000 mL (minor adjustments
may be made for climate and activity).
• Avoid inadequate or excessive fluid intake on the basis of an
FVC.
• Advise fluid restriction when symptoms are most inconvenient
(e.g., during long journeys or when out in public).
• Advise evening fluid restriction for nocturia (no fluid for 2
hours before retiring).
Lifestyle and Dietary Modifications: Caffeine and Alcohol (3)
Caffeine and Alcohol
• Avoid caffeine by replacing caffeine with alternatives (e.g.,
decaffeinated or caffeine-free drinks).
• Avoid alcohol in the evening if nocturia is bothersome.
• Replace large-volume alcoholic drinks (e.g., pint of beer) with
small-volume alcoholic drinks (e.g., wine or spirits).
Lifestyle and Dietary Modifications: Concurrent Medication (2)
• Adjust the time when medication with an effect on the urinary
system is taken to reduce LUTS at times of greatest inconvenience
(e.g., during long journeys and when out in public).
• Replace antihypertensive diuretics with suitable alternatives
with fewer urinary effects (via the patient’s general practitioner).
Lifestyle and Dietary Modifications: Types of Toileting and Bladder Retraining (3)
• Advise men to double-void (spending extra time on the toilet
to try to empty the bladder completely).
• Advise urethral milking for men with postmicturition dribbling.
• Advise bladder retraining. With use of distraction techniques
(predetermined mind exercise, perineal pressure, or pelvic floor
exercises), aim to increase the minimum time between voids
to 3 hours (daytime) and/or the minimum voided volume to
between 200 and 400 mL (daytime). The urge to void should
be suppressed for 1 minute, then 5 minutes, then 10 minutes,
and so on, increasing on a weekly basis. Use FVCs to monitor
progress.
Medical therapy is the first-line treatment for patients _______.
bothered by LUTS without imperative indications for surgery, such as the occurrence of AUR, recurrent UTIs, renal insufficiency, bladder stones, and recurrent gross hematuria
Drug therapy should be tailored to the patient’s symptoms:
In a patient with predominantly voiding symptoms: _____
predominant storage symptoms: _____
In a patient with predominantly voiding symptoms: α1-blockers, 5ARIs and PDE5Is may be all valid treatment options
predominant storage symptoms: muscarinic receptor antagonists or β3-agonists
The goals of LUTS medical treatment may include: ______ (6)
relieving symptoms,
decreasing BOO,
improving bladder emptying,
ameliorating DO,
reversing renal insufficiency, and
preventing disease progression, defined as symptom deterioration and/or the occurrence
of complications requiring surgical treatment.
_______ , are considered the gold standard to quantify the impact of therapeutic interventions on LUTS.
The mean changes in the AUASI score for patients rating their symptoms
as markedly, moderately or slightly relieved, unchanged, or worse: _____
A minimum of a ____ change in terms of the symptom score appears perceptible to patients.
Changes in patients’ symptoms, as assessed with validated tools such as the AUASI or the IPSS
markedly relieved: −8.8 moderately relieved: −5.1 slightly relieved: −3.0 unchanged: −0.7 worse: +2.7
3-point change = perceptible
_____ are the gold standard for the assessment and quantification of BOO;
however, as an invasive test, this modality is not suggested for the evaluation of treatment outcomes in clinical practice.
PFSs
Several studies used uroflowmetry parameters to compare the efficacy of different
LUTS treatments; of those, _____ is considered an indirect measure of BOO
PFR (Qmax)
An urodynamic profile characterized by _____ suggests DO, which may be spontaneous or provoked
involuntary detrusor contractions during the filling phase
** Of clinical relevance, urodynamically demonstrated DO is not
invariably associated with OAB syndrome
There is an important placebo effect in LUTS outcome measures.
Ideally a _____ period before initiation of treatment
should be included in any trial design; this would allow the
incorporation of a baseline placebo effect before any comparison
is made.
4-week placebo run-in
Total of nine AR subtypes: the ____ plays a major role in the pathophysiology of LUTS and is the target of α1-blockers.
α1-AR subfamily
MOA of α1-ARs: _____
Noradrenaline-mediated contraction of the smooth muscle via the binding with α1-ARs (mainly α1a subtype) at the level of the bladder neck, the proximal urethra, and the prostate is responsible for the dynamic component of BOO in patients with BPH;
therefore, the blockade of α1-ARs leads to the relaxation of smooth muscle tissue at both sites, with a decrease of the sympathetic baseline muscle tone and the consequent relief of symptoms.
** The effect of α1-blockers on bladder detrusor function has not yet been clarified.
Phenoxybenzamine: Non-selective α1-blocker outcomes: ____
nonselectivity of the molecule, blocking both α1 and α2 receptor subtypes, serious cardiovascular AEs were observed, and the drug was no longer used to treat LUTS/BPH.
____ was the first selective α1-AR antagonist investigated for LUTS treatment. Resulted in a significant increase in urinary flow rates and better tolerated than phenoxybenzamine.
Short serum elimination half-life, requires administration at least ___ daily.
Prazosin
Twice
____ are defined as uroselective drugs and have a higher affinity for the α1a and α1d receptor subtypes than for the α1b subtype.
Tamsulosin, alfuzosin, silodosin, and naftopidil
Lepor et al., 1992: TERAZOSIN
Phase III Multicenter Trial
285 patients with LUTS suggestive of BOO randomized to
receive placebo or 2 mg, 5 mg, or 10 mg terazosin once daily for a
12-week treatment period
RESULTS: _____
AEs: _____
- 4% reduction in symptom score (Boyarsky symptom scale) in favor of the treatment
group.
Moreover, patients treated with terazosin had a significant increase in PFRs and mean urinary flow rates.
Both effects were dose dependent, with better results with 10 mg terazosin.
Overall, AEs were minor and reversible in all four terazosin treated groups.
Dizziness and asthenia were the most commonly reported AEs in the terazosin group (26% and 14%, respectively);
Hytrin Community Assessment Trial (HYCAT)
2084 men with an AUASI score of 13 or greater and a PFR of less
than 15 mL/s
Patients were randomized to receive placebo or terazosin;
the dose was titrated from 1 mg to 5 mg or 10 mg according
to the clinical response
RESULTS: ____
AEs: ____
The symptom score decreased by 37.8% in the terazosin group and by 18.4% in the placebo group (P < 0.001)
similarly treatment with terazosin significantly improved urinary flow parameters.
AEs: Of note, 19.7% of patients discontinued use of terazosin because of AEs.
