CUA GL 2018 BPH Flashcards
What diagnostic tests are mandatory for someone presenting with BPH/LUTS?
History, physical( including DRE), Urinalysis
What are recommended investigations?
IPSS
AUA-SI
PSA( if life expectancy >10 or knowing PSA would change management, help estimate prostate Size)
What is optional?
serum creatinine, uroflowmetry, PVR, sexual function questionnaire, voiding diary(including frequency volume charts for those suspected of having nocturnal polyuria), urine cytology,
What tests are not recommended?
cytology, cystoscopy, UDS, radiological evaluation of upper tract, prostate US, prostate biopsy
What are indications for BPH/MLUTS surgery?
Recurrent UTIs, Recurrent or refractory urinary retention, bladder stones, renal dysfunction secondary to BPH, recurrent hematuria, symptom deterioration despite medical therapy, patient preference
what procedures/investigations should be done before intervention
Cystoscopy( to determine prostate size and presence of significant median lobe)
Recommended: US(abdominal or TRUS) to help determine modality of surgery.
Which patient should be advised to do lifestyle modifications/ watchful waiting?
mild symptoms, IPSS<7, if they have severe bother can also offer them treatment.
What are lifestyle changes that can be offered to patients with non-bothersome symptoms?
1- Fluid restriction, particularly before bedtime
2- Avoidance of caffeinated beverages, alcohol and spicy foods
3- avoidance/monitoring of some drugs(diuretics, decongestants, antihistamines, antidepressants)
4- Pelvic floor exercises
5-avoidance or treatment of constipation
6- Timed or organized voiding(bladder retraining)
What are first line medical therapies for men with symptomatic bother? name 5. which one requires dose titration
alpha blockers: Alfuzosin, doxazosin, terazosin, silodosin(most potent alpha 1-a blocker) , tamsulosin(IFIS)
doxazosin and terazosin need dose titration
Name 3 benefits of ARIs for BPH?
1- 25-30% volume reduction of prostate
2- decrease risk of urinary retention
3- decrease the need for surgical intervention
seems to work best in patients with PSA>1.5 and Prostate volume>30cc
alpha blockers dont do this
name 3 factors suggesting risk of BPH progression?
PSA>1.4, Prostate V>30, age>50
what are benefits of combination therapy? can you dc alpha blockers after a while if there is a good response
Improve flow rates, improved symptom score, decreased risk of urinary retention, decreased risk of prostate surgery
yes, after 6-9 months
What PVR would be concerning if prescribing someone antimuscarinics or beta 3 agonists.
250-300, older age be cautious they say in the guideline
What can you offer someone with combination storage and voiding symptoms
alpha blocker and beta 3 agonist or antimuscarinics
What is recommended for men with ED and MLUTS/BPH?
long acting PDE5i(tadalafil 5mg), studies have shown improvement in IPSS, storage and voiding symptoms and quality of life
What is recommended in men with nocturnal polyuria?
desmopressin( an arginine vasopressin (AVP), ADH analogue) , check Sodium 7 days post and 30 days.
are there any phythotherapies recommended for MLUTS, BPH?
No
What are complications of TURP?
Bleeding, infection, capsular perforation, TUR syndrome, bladder neck contracture, incontinence, retrograde ejaculation, ED, surgical retreatment(2% per year)
Who should have M-TURP? What about B-TURP?
moderate to severe symptoms V: 30-80 cc
Same as M-TURP but has lower morbidity
who should have bipolar plasma kinetic vaporization of prostate(BPKVP)?
Prostate <60ml, shorter OR time, cath time, hospital stay,. comparable peak flow rates, PSA reduction, IPSS to M-TURP
who do they recommend open simple for?
Prostate>80ml, concurrent open bladder procedure(stones, diverticulum), inability to place patient in dorsal lithotomy position due to severe hip disease
who is PVP recommended for?
alternative in men with moderate to severe LUTS
men on anticoagulation or high cardiovascular risk
Who should have HoLEP?
anyone, if surgeon can do it
Who sould have diode laser vaporization
alternate surgical approach for men on anticoagulation
What about thulium Yag?
alternative treatment. can do it for small or large glands
What is the role of TUIP?
Prostate<30ml without a middle lobe
Who should have TUMT?
carefully selected well informed men, outpatient procedure, retreatment rate at 5 years 42-59%
What is the role of Transurethral needle ablation (TUNA):
No role, they suggest we don’t offer it, high retreatment rates
What are complications of prostatic stents? what’s their role?
migration, encrustation, exacerbation of LUTS, misplacement, For unfit patients for surgery as an alternative to catheterization if they got a functional detrusor
What is the role of UroLift?
Prostate<80ml, no middle lobe and interested in preserving ant ejaculation. durable but less effective than TURP
Who can have Rezum(convective water vapor energy ablation)?
Prostate<80ml, can have middle lobe, interested in preserving anti ejaculation… NOTE: this is different from waterjet ablation. waterjet ablation can be given to guys with prostate<80ml with or without middle lobe and is better than TURP for ejaculation
What is the role of temporary implantable nitinol device?
no role right now, dont offer it, in research
What are complications of prostatic artery embolization?
non targeted embolization can lead to : transient ischemic proctitis, bladder ischemia, urehtral and ureteral stricture and seminal vesicle ischemia
Should you offer prostate artery embolization to patients?
No
can you offer 5-ARI to patients with symptomatic prostate enlargement in the absence of significant bother
yes, to prevent progression of disease
We suggest that men with AUR secondary to BPH
may be offered…….
therapy during the period of
catheterization
alpha-blocker
We suggest that a trial with a ……is appropriate in men
with BPH-related hematuria
a 5ARI
