Canadian Urological Association guideline: Male lower urinary tract symptoms/ benign prostatic hyperplasia Flashcards
What is the purpose of the updated Canadian Urological Association (CUA) BPH guideline document?
The document summarizes state-of-the-art knowledge related to the management of male lower urinary tract symptoms (MLUTS) secondary to benign prostatic hyperplasia (BPH). It updates the 2018 CUA BPH guideline and highlights essential diagnostic and therapeutic information in a Canadian context.
What is the scope of the literature review conducted for the CUA BPH guideline update?
The literature review includes information reviewed for the 2010 guideline, an updated MEDLINE search of the English-language literature (using a variety of search terms related to BPH treatment methods), and a review of the most recent American Urological Association (AUA) and European Association of Urology (EAU) guidelines. The management recommendations are based on literature published between 2000 and 2021.
Who are the guidelines directed towards?
The guidelines are primarily directed towards the typical male patient over 50 years of age presenting with LUTS and benign prostatic enlargement (BPE) and/or benign prostatic obstruction (BPO). However, they also apply to non-binary people, transwomen, and any patients who may have anatomical features of a cis-male genitourinary tract, such as a prostate.
How are diagnostic guidelines described in the document?
Diagnostic guidelines are described in the following terms: mandatory, recommended, optional, or not recommended. These recommendations were developed based on clinical principle and/or expert opinion.
How are treatment guidelines described in the document?
Treatment guidelines are described using the GRADE approach for summarizing the evidence and making recommendations.
What are the mandatory evaluations recommended in the diagnostic guidelines of the 2018 CUA BPH?
The mandatory evaluations include:
Patient history
Physical examination, including a digital rectal exam (DRE)
Urinalysis
What is the purpose of the initial evaluation of a man presenting with LUTS according to the CUA BPH guidelines?
The purpose of the initial evaluation is to assess symptom severity and bother. It should include a review of relevant prior and current illnesses, prior surgery, and trauma. It is also mandatory to review current medication, including over-the-counter drugs and phyto-therapeutic agents.
Why is a focused physical examination, including a digital rectal exam (DRE), mandatory?
A focused physical examination, including a DRE, is mandatory to provide information about the prostate that might influence the management of LUTS.
Why is urinalysis required?
Urinalysis is required to rule out diagnoses other than BPH that may cause LUTS and may require additional diagnostic tests.
What is the purpose of using a formal symptom inventory (e.g., International Prostate Symptom Score [IPSS] or AUA Symptom Index [AUA-SI]) in the management of male lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH)?
A formal symptom inventory is recommended for an objective assessment of symptoms at initial consultation, for follow-up of symptom evolution for those on watchful waiting, and for evaluation of response to treatment.
In the context of LUTS/BPH, to whom should testing of prostate-specific antigen (PSA) be offered?
Testing of PSA should be offered to patients who have at least a 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.
How can serum PSA be a useful marker in patients without prostate cancer?
Among patients without prostate cancer, serum PSA may be a useful surrogate marker of prostate size and may also predict risk of BPH progression.
What are some optional tests that a physician might order when there is diagnostic uncertainty in a case of male lower urinary tract symptoms/benign prostatic hyperplasia?
The optional tests could include:
Serum creatinine
Urine cytology
Uroflowmetry
Postvoid residual (PVR)
Voiding diary (recommended frequency volume chart for men with suspected nocturnal polyuria)
Obstructive Sleep Apnea (OSA) screening for men with nocturia over the age of 50 (STOP BANG questionnaire)
Sexual function questionnaire
When is a voiding diary recommended, according to the Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia?
A voiding diary (frequency volume chart) is recommended for men with suspected nocturnal polyuria.
For men with nocturia over the age of 50, what kind of screening is recommended by the Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia?
Obstructive Sleep Apnea (OSA) screening is recommended. This is typically performed using the STOP BANG questionnaire.
According to the Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia, what type of questionnaire might be used to evaluate sexual function?
A sexual function questionnaire may be used to evaluate sexual function.
What does the acronym “PVR” stand for in the context of urology, and when might it be used according to the Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia?
“PVR” stands for Postvoid Residual. It may be used when there is diagnostic uncertainty in a case of male lower urinary tract symptoms/benign prostatic hyperplasia.
What are the diagnostic modalities not recommended in the routine initial evaluation of a typical patient with BPH-associated LUTS?
The diagnostic modalities that are not recommended in the routine initial evaluation of a typical patient with BPH-associated LUTS include:
Cytology
Cystoscopy
Urodynamics
Radiological evaluation of the upper urinary tract
Prostate ultrasound
Prostate biopsy
These investigations may be required in patients with another indication, such as hematuria, diagnostic uncertainty, DRE abnormalities, poor response to medical therapy, or for surgical planning.
In which situations might the non-recommended diagnostic modalities be required for a patient with BPH-associated LUTS?
The non-recommended diagnostic modalities might be required in the following situations:
Presence of hematuria
Diagnostic uncertainty
DRE abnormalities
Poor response to medical therapy
For surgical planning
Figure 1
Algorithm of appropriate diagnostic steps in the workup of a typical patient with male lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH). PE: physical exam; PSA: prostate-specific antigen; PVR: postvoid residual; U/A: urinalysis.
What are the seven indications for MLUTS/BPH surgery according to the Canadian Urological Association guideline?
The indications include:
Recurrent or refractory urinary retention
Recurrent urinary tract infections (UTIs)
Bladder stones
Recurrent hematuria
Renal dysfunction secondary to BPH
Symptom deterioration despite medical therapy
Patient preference.
Is the presence of a bladder diverticulum an absolute indication for MLUTS/BPH surgery?
No, the presence of a bladder diverticulum is not an absolute indication for surgery unless associated with recurrent UTI or progressive bladder dysfunction.
Which tests are recommended preoperatively for patients in whom MLUTS/BPH surgery is being considered?
Cystoscopy should be performed to evaluate prostate size, as well as presence or absence of significant middle/median lobe and/or bladder calculi. Ultrasound (either by transrectal ultrasound [TRUS] or transabdominal US) is recommended to determine the volume of the prostate and the extent of median lobe presence in order to select appropriate modality of surgical therapy. Information can also be obtained from a recent abdominal computed tomography (CT) or magnetic resonance imaging (MRI).
Why is the determination of prostate size and extent of median lobe important before MLUTS/BPH surgery?
The determination of prostate size and extent of median lobe are related to procedure-specific indications. They inform the selection of the appropriate modality of surgical therapy.
What are the purposes of preoperative cystoscopy and ultrasound in the context of MLUTS/BPH surgery?
Cystoscopy is performed to evaluate the prostate size, as well as the presence or absence of significant middle/median lobe and/or bladder calculi. Ultrasound is used to determine the volume of the prostate and the extent of median lobe presence. These assessments guide the selection of the appropriate modality of surgical therapy.
What principles should guide therapeutic decision-making for BPH?
The severity of the symptoms, the degree of bother, and patient preference should guide therapeutic decision-making for BPH. Patients should be informed about the risks and benefits of all treatment options if they are bothered enough to consider therapy. A shared decision-making approach should be used to determine the best treatment for the patient.
What is the suggested approach for patients with mild BPH symptoms (e.g., IPSS <7)?
Patients with mild symptoms should be counseled about a combination of lifestyle modification and watchful waiting. If these patients have severe bother, they should undergo further assessment.
What are the treatment options for patients with moderate (e.g., IPSS 8–18) and severe (e.g., IPSS 19–35) BPH symptoms?
Treatment options include watchful waiting/lifestyle modification, medical therapy, minimally invasive therapy, and surgical therapies.
What factors should physicians use to advise patients on their individual risk of symptom progression, acute urinary retention (AUR), or future need for BPH-related surgery?
Physicians should use baseline age, LUTS severity, and prostate volume to advise patients on their individual risk of symptom progression, acute urinary retention, or future need for BPH-related surgery.
What lifestyle changes may be suggested for patients with non-bothersome BPH symptoms?
Suggested lifestyle changes include fluid restriction (especially before bedtime), avoidance of caffeinated beverages, alcohol, spicy foods, and certain drugs (diuretics, decongestants, antihistamines, antidepressants), timed or organized voiding (bladder retraining), avoidance or treatment of constipation, weight loss, prevention or treatment of conditions associated with metabolic syndrome, and pelvic floor physical therapy in cases of suspected non-relaxing pelvic floor dysfunction or overactive bladder and/or urinary incontinence.
What is the recommended follow-up protocol for patients on watchful waiting for BPH?
Patients on watchful waiting should have periodic physician-monitored visits to monitor for any complications associated with their BPO. Physicians should assess either progression of bother, using a validated questionnaire such as IPSS (subjective), or worsening urinary function, using uroflowmetry or PVR (objective).
What should be assessed during follow-up visits for patients started on medical therapy for BPH?
Follow-up visits for patients on medical therapy should assess the efficacy and safety (side effects) of medications. If the patient-directed therapeutic goal is achieved, the patient may be followed by the primary care physician as part of a shared-care approach. The primary care physician should be counseled with clear instructions on follow-up and re-referral as necessary.
What is the recommended follow-up protocol for patients who receive prostate surgery for BPH?
Patients who receive prostate surgery for BPH should be reviewed 4–6 weeks after catheter removal to evaluate treatment response, using symptom assessment (e.g., IPSS), and if indicated, uroflowmetry and PVR volume. Side effects and adverse events should also be screened for. The need for and type of further follow-up will be determined by the individual patient’s circumstances and the type of surgical procedure employed.
What are some of the alpha-blockers recommended for the treatment of LUTS secondary to BPH?
Alfuzosin, doxazosin, tamsulosin, terazosin, and silodosin are recommended for the treatment of LUTS secondary to BPH.
Which alpha-blockers require dose titration and blood pressure monitoring?
Doxazosin and terazosin require dose titration and blood pressure monitoring.
What is the impact of alpha-blockers on the natural progression of BPH?
Alpha-blockers do not alter the natural progression of BPH. They have little impact on prostate growth, risk of urinary retention, or the need for BPH-related surgery.
What is the most common adverse effect associated with alpha-blockers?
The most common adverse effect associated with alpha-blockers is dizziness, with the highest rates for terazosin and doxazosin.
Which alpha-blockers are most often reported with ejaculatory disturbances?
Ejaculatory disturbances are most often reported with tamsulosin and silodosin.
What is Floppy iris syndrome and with which alpha-blocker is it most commonly associated
Floppy iris syndrome has been reported in patients on alpha-blockers, particularly tamsulosin. It’s not an issue in men with no planned cataract surgery and can be managed by the ophthalmologist.
Which factors should influence the choice of alpha-blocker for a patient?
The choice of alpha-blocker should depend on the patient’s comorbidities, side effect profile, and tolerance.
According to the Canadian Urological Association guidelines, what is the recommendation for alpha-blockers in the treatment of BPH?
What are the proven benefits of 5-ARI therapy for BPH?
5-ARI therapy improves symptoms, shrinks the prostate by 25-30%, and can alter the natural history of BPH by reducing the risk of acute urinary retention (AUR) and the need for surgical intervention.
In which patients is the efficacy of 5-ARI treatment noted?
Efficacy of 5-ARI treatment is noted in patients with a prostate volume greater than 30 cc and/or PSA levels greater than 1.5 ng/ml.
What are the potential side effects of 5-ARI treatment?
5-ARI treatment is associated with erectile dysfunction, decreased libido, ejaculation disorders, and rarely, gynecomastia and post-finasteride syndrome.
What is the recommendation for the use of 5-ARIs (dutasteride and finasteride) in the treatment of LUTS associated with prostatic enlargement?
5-ARIs (dutasteride and finasteride) are recommended as appropriate and effective treatment for patients with LUTS associated with demonstrable prostatic enlargement.
What are the prognostic factors suggesting the potential for BPH progression risk?
Serum PSA >1.4 ng/mL, age >50 years, and gland volume >30 cc.
How does combination therapy (alpha-blocker and 5-ARI) affect symptom score and peak urinary flow compared to monotherapy options?
Combination therapy significantly improves symptom score and peak urinary flow compared to either of the monotherapy options.
What are the potential side effects of combination therapy for BPH?
Combination medical therapy is associated with an increased risk of side effects, particularly ejaculatory disturbances.
For which patients is the combination of an alpha-adrenergic receptor blocker and a 5-ARI recommended?
This combination is recommended for patients with symptomatic LUTS associated with prostatic enlargement (>30 cc).
When might it be appropriate to consider discontinuing the alpha-blockers in patients successfully managed with combination therapy for BPH?
It may be appropriate to consider discontinuing the alpha-blockers after 6–9 months of combination therapy.
What is the recommended course of action if symptoms recur after discontinuing the alpha-blocker in a patient with BPH?
If symptoms recur, the alpha-blocker should be restarted.
What are the common storage symptoms associated with Male Lower Urinary Tract Symptoms (MLUTS) in the context of Benign Prostatic Hyperplasia (BPH)?
The common storage symptoms associated with MLUTS in BPH are urgency, frequency, and nocturia.
What improvements have antimuscarinics (anticholinergics) and beta-3 agonists shown in male storage LUTS (with and without BPH)?
These medications have shown reductions in frequency, urgency, and urgency incontinence episodes.
Name some contemporary antimuscarinics used in treating male storage LUTS.
Contemporary antimuscarinics include tolterodine and fesoterodine.
Figure 2. Male lower urinary tract symptoms/benign prostatic hyperplasia (MLUTS/BPH) management algorithm. ED: erectile dysfunction; PDE5: phosphodiesterase type 5; PSA: prostate-specific antigen.
Figure 3. Treatment algorithm of bothersome lower urinary tract symptoms (LUTS) refractory to conservative/medical treatment or in cases of absolute operation indications.
