EAU 2020 Non-Neurogenic Male LUTS Flashcards
Definition:
Acute urinary retention
Acute retention of urine is defined as a painful, palpable or percussible bladder, when the patient is unable to pass any urine.
Definition:
Chronic urinary retention
Chronic retention of urine is defined as a non-painful bladder, which remains palpable or percussible after the patient has passed urine. Such patients may be incontinent.
Definition:
Bladder outlet obstruction
Bladder outlet obstruction is the generic term for obstruction during voiding and is characterised
by INCREASED DETRUSOR PRESSURE and REDUCED URINE FLOW RATE. It is usually diagnosed by studying the
synchronous values of flow-rate and detrusor pressure
Definition:
Benign prostatic obstruction
A form of BOO and may be diagnosed when the cause of outlet obstruction is known to be BPE.
Definition:
Benign prostatic hyperplasia
Benign prostatic hyperplasia is a term used (and reserved) for the typical histological pattern, which
defines the disease.
Definition: Detrusor overactivity (DO)
Detrusor overactivity (DO) is a urodynamic observation characterised by INVOLUNTARY DETRUSOR CONTRACTIONS during the FILLING PHASE which may be spontaneous or provoked.
Definition:
Overactive bladder syndrome
Overactive bladder syndrome is characterised by urinary URGENCY, with or without urgency urinary incontinence, usually with INCREASED DAYTIME FREQUENCY and NOCTURIA, if there is no proven infection or other obvious pathology
Frequency volume charts record:
A bladder diary records:
FVC: volume and time of each void
Bladder diary: FVC + fluid intake, use of pads, activities during recording, symptom scores
___ and ___ day FVCs provide reliable measurement of urinary symptoms in patients with LUTS.
Three and seven day FVCs.
Recommendation:
Use a bladder diary to assess male LUTS with:
A prominent storage component or nocturia.
Recommendation:
Tell the patient to complete a bladder diary for at least ____ days.
Three
DRE has ______ correlation to actual prostate volume, especially where volume > 30 mL.
Poor correlation
Recommendation:
Perform a physical examination including ____ in the assessment of male LUTS.
DRE
Recommendation: Use urinalysis (by \_\_\_\_ or \_\_\_\_\_) in the assessment of male LUTS.
Dipstick or urinary sediment
Age-specific criteria (PSA level) for detecting men with prostate glands > 40 mL:
50s: ___
60s: ___
70s: ___
50s: > 1.6 ng/mL
60s: > 2.0 ng/mL
70s: > 2.3 ng/mL
Recommendation:
Measure prostate-specific antigen (PSA) if: ___ and ___
If a diagnosis of prostate cancer will change management
AND
if it assists in the treatment and/or decision making process.
Recommendation:
Assess renal function if: ___
Renal impairment is suspected based on history and clinical examination, or in the presence of hydronephrosis,
OR
when considering surgical treatment for male LUTS.
The diagnostic accuracy of PVR measurement, using a PVR threshold of ______, has a PPV of 63% 3 and a NPV of 52% for the prediction of ____.
50 mL
BOO
Uroflowmetry:
Key parameters (2): ____, ____
Voided volume should be: _____
Repeat uroflow if (2): ____ or _____
Key parameters : Qmax, flow pattern
Voided volume should be: >150mL
Repeat uroflow if (2): <150 mL voided volume or abnormal flow pattern
Recommendation:
Perform uroflowmetry in the initial assessment of male LUTS and _______.
Prior to medical or invasive treatment.
Is VCUG recommended in the routine diagnostic workup of male LUTS?
No.
BUT, it may be useful for the detection of vesico-ureteral reflux, bladder diverticula, or urethral pathologies. RUG may be useful for stricture evaluation.
Patients with (3) ______ who present with LUTS should undergo urethrocystoscopy.
Micro or gross hematuria
Urethral stricture
Bladder cancer
Recommendation:
Perform urethrocystoscopy in men with LUTS prior to ____ if _____.
Prior to minimally invasive/surgical therapies if the findings may change treatment.
Recommendation:
Perform PFS in the following situations (5):
- Previous unsuccessful (invasive) treatment for LUTS)
- Considering invasive treatment but cannot void >150mL
- Considering surgery, predominantly voiding LUTS, Qmax > 10 mL/s
- Considering invasive therapy, bothersome voiding LUTS with PVR > 300 mL
- Considering invasive treatment, bothersome voiding LUTS >80years old or <50years old
Recommendation:
Do NOT offer ________ as an alternative to ______ for diagnosing bladder outlet obstruction in men.
Non-invasive tests
Pressure flow studies
” It was found that specificity, sensitivity, PPV and NPV of the non-invasive tests were highly variable. Therefore, even though several tests have shown promising results regarding non-invasive diagnosis of BOO, invasive urodynamics remains the modality of choice.”
Watchful waiting is usually a safe alternative for:
Men who are less bothered by urinary difficulty
OR
who wish to delay treatment.
The treatment failure rate over a period of five years was 21%; 79% of patients were clinically stable.
Recommendation:
Offer WW to men with (2):
- Mild/moderate symptoms
- Minimally bothered by their symptoms
💊 ⍺1-blockers
MOA: Inhibit the effect of endogenously released noradrenaline on smooth muscle cells in the prostate and thereby reduce prostate tone and BOO
Efficacy: Reduces IPSS and improves Qmax; does NOT reduce prostate size, does NOT prevent AUR
Safety: Intraop floppy iris syndrome (IFIS), abnormal ejaculation, orthostatic hypotension
Do ⍺1-blockers cause retrograde ejaculation?
Thanos FAQ
No. Only abnormal ejaculation.
“Originally, abnormal ejaculation was thought to be retrograde, but more recent data demonstrate that it is due to a decrease or absence of seminal fluid during ejaculation, with young age being an apparent risk factor.”
Recommendation:
Offer ⍺1-blockers to men with:
Moderate-to-severe LUTS.
5-ARI type predominant in the prostate:
5α-reductase type 2: predominant expression and activity in the prostate.
Dutasteride inhibits both types 1 and 2. Finasteride: only type 2.
💊 5-ARIs
MOA: Androgen effects on the prostate are mediated by dihydrotestosterone (DHT), which is converted from testosterone by the enzyme 5α-reductase.
Efficacy: Improve IPSS by approximately 15-30%, decrease 1b prostate volume by 18-28%, and increase Qmax by 1.5-2.0 mL/s in patients with LUTS due to prostate enlargement.
Prevents AUR and need for surgery.
Adverse events: reduced libido, ED, retrograde ejaculation, decreased semen volume, gynecomastia.
Recommendation:
Use 5α-reductase inhibitors in men who have: ____.
Counsel patients about onset of action of 5-ARIs: ____ months
Moderate-to-severe LUTS and an increased risk of disease progression (e.g. prostate volume > 40 mL).
Counsel patients about the onset of action (three to six months) of 5α-reductase inhibitors.
💊 Muscarinic receptor antagonists: MOA
Blocks muscarinic receptors (M2 and M3 are predominant in the detrusor) which are stimulated by neurotransmitter acetylcholine from parasympathetic nerves.
Efficacy: monotherapy can improve urgency, UUI, daytime frequency;
Safety: may increase PVR; AUR is rare in men with PVR < 150 mL at baseline
Recommendation:
Use muscarinic receptor antagonists in men with:
Moderate-to-severe LUTS who mainly have bladder storage symptoms.
Recommendation:
Do not use antimuscarinic overactive bladder medications in men with:
PVR > 150 mL.
💊 PDE5Is
MOA: Increase intracellular cyclic guanosine monophosphate, thus reducing smooth muscle tone of the detrusor, prostate and urethra.
Efficacy: Improve IPSS and IIEF score, but not Qmax.
Safety: contraindicated in patients using nitrates, nicorandil, doxazosin and terazosin, stable angina pectoris, recent MI, poorly controlled BP, hepatic or renal insufficiency
Recommendation:
Use phosphodiesterase type 5 inhibitors in men with:
Moderate-to-severe LUTS with or without erectile dysfunction.
Saw palmetto
Serenoa repens
Fruit
Only hexane extracted Serenoa repens has been recommended for well-established use by the HMPC.
Other phytotherapy substances (4)
Pumpkin seed (Cucurbita pepo)
Pygeum africanum bark (Prunus africana)
Urtica dioica L., Urtica urens L. and their hybrids
Willow herb (Epilobium angustifolium and Epilobium parviflorum)
💊 Beta-3 agonists
MOA: Beta-3 adrenoceptors are the predominant beta receptors expressed in the smooth muscle cells of the detrusor and their stimulation is thought to induce detrusor relaxation. The mode of action of beta-3 agonists is not fully elucidated.
Efficacy: Improves the symptoms of OAB, including micturition frequency, urgency and UUI.
Safety: Most common AEs: hypertension, UTI, headache and nasopharyngitis. Contraindicated in severe uncontrolled hypertension (SBP > 180 or DBP > 110)
Recommendation:
Use beta-3 agonists in men with:
Moderate-to-severe LUTS who mainly have bladder storage symptoms.
💊 alpha1-blockers + 5-ARIs
Efficacy:
MTOPS and CombAT studies : combination treatment is superior to monotherapy for symptoms and Qmax, and superior to α1-blocker alone in reducing the risk of AUR or need for surgery.
MTOPS: Reduced risk of long-term clinical progression
CombAT: Reduced risk of AUR and BPH-related surgery, and symptom deterioration
Adverse events: combined!
“CombAT trial!”
Recommendation:
Offer combination treatment with an α1-blocker and a 5α-reductase inhibitor to
Men with moderate-to-severe LUTS and an increased risk of disease progression (e.g. prostate volume > 40 mL).
💊 α1-blockers + muscarinic receptor antagonists
Efficacy:
Improves LUTS-related QoL impairment
Reduces urgency, UUI, voiding frequency, nocturia, or IPSS compared with α1-blockers or placebo alone.
Low risk of AUR using α1-blockers and antimuscarinics in men known to have a PVR urine volume of < 150 mL.
Adverse Events:
Combined!
Recommendation:
Use combination treatment of a α1-blocker with a muscarinic receptor antagonist in:
Patients with moderate-to-severe LUTS if relief of storage symptoms has been insufficient with monotherapy with either drug.
Recommendation:
Do NOT prescribe combination treatment (alpha1-blockers + muscarinic blockers) in:
Men with a post-void residual volume > 150 mL.
Monopolar TURP is the standard procedure for:
Men with prostate sizes of 30-80 mL and bothersome moderate-to-severe LUTS secondary of BPO.
Transurethral incision of the prostate shows similar efficacy and safety to M-TURP for:
Treating moderate-to-severe LUTS secondary to BPO in men with prostates < 30 mL.
Compared to TURP, TUIP has significantly lower _____ but has higher _____.
Lower retrograde ejaculation rate
Higher reoperation rate
Bipolar TURP achieves short-, mid- and long-term results comparable with M-TURP, but B-TURP has a more favourable:
Peri-operative safety profile.
Plasmakinetic B-TUVP has a favourable _____, similar ______, but inferior ______ compared to TURP.
Favorable peri-operative profile
Similar mid-term safety
Inferior mid- term efficacy
Plasma B-TUVP has a _______ compared to TURP.
Lower short-term major morbidity rate
The choice between TUIP and TURP should be based primarily on:
Prostate volume
< 30 mL: TUIP
30-80 mL: TURP
Recommendation:
Offer transurethral incision of the prostate to surgically treat:
Moderate-to-severe LUTS in men with prostate size < 30 mL, without a middle lobe.
Recommendation:
Offer bipolar- or monopolar-transurethral resection of the prostate (TURP) to surgically treat:
Moderate-to-severe LUTS in men with prostate size of 30-80 mL.
Recommendation:
Offer bipolar transurethral vaporisation of the prostate as an alternative to monopolar TURP to surgically treat:
Moderate-to-severe LUTS in men with prostate size of 30-80 mL.
Recommendation:
Offer open prostatectomy in the absence of endoscopic enucleation to treat:
Moderate-to- severe LUTS in men with prostate size > 80 mL.
HoLEP MOA
The holmium:yttrium-aluminium garnet (Ho:YAG) laser (wavelength 2,140 nm) is a pulsed solid-state laser that is absorbed by water and water-containing tissues.
Tissue coagulation and necrosis are limited to 3-4 mm, which is enough to obtain adequate haemostasis.
HoLEP advantages over TURP and OP
Laser enucleation of the prostate using Ho:YAG laser (HoLEP) demonstrates HIGHER HEMOSTASIS and INTRAOP SAFETY when compared to TURP and OP.
Greenlight laser MOA
The Potassium-Titanyl-Phosphate (KTP) and the lithium triborate (LBO) lasers work at a wavelength of 532 nm. Laser energy is absorbed by haemoglobin, but not by water. Vaporisation leads to immediate removal of prostatic tissue.
Advantages and disadvantages of laser vaporisation vs. TURP
A: Higher intra-operative safety with regard to haemostatic properties when compared to TURP, catheterisation time and hospital stay are in favour
of PVP
D: Operation time and risk of re-operation are in favour of TURP
Laser vaporisation of the prostate using the 80-W KTP and 120-W LBO lasers seems to be safe for:
Treatment of patients receiving antiplatelet or anticoagulant therapy.
Recommendations:
Offer 80-W 532-nm Potassium-Titanyl-Phosphate (KTP) laser vaporisation of the prostate to men with:
Moderate-to-severe LUTS with a prostate volume of 30-80 mL as an alternative to transurethral resection of the prostate (TURP).
Recommendations:
Offer 120-W 532-nm Lithium Borat (LBO) laser vaporisation of the prostate to men with:
Moderate-to-severe LUTS with a prostate volume of 30-80 mL as an alternative to TURP
Recommendations:
Offer 180-W 532-nm LBO laser vaporisation of the prostate to men with:
Moderate-to- severe LUTS with a prostate volume of 30-80 mL as an alternative to TURP.
Recommendations:
Offer laser vaporisation of the prostate using 80-W KTP, 120- or 180-W LBO lasers for the treatment of:
Patients receiving antiplatelet or anticoagulant therapy with a prostate volume < 80 mL.
Recommendation:
Offer 120-W 980 nm diode laser vaporisation of the prostate to men with:
Moderate-to- severe LUTS as a comparable alternative to transurethral resection of the prostate (TURP).
Recommendation:
Offer 120-W 980 nm diode laser or 1,318 nm diode laser enucleation of the prostate to men with:
Moderate-to-severe LUTS as a comparable alternative to TURP or bipolar enucleation.
Recommendation:
Offer laser enucleation of the prostate using Tm:YAG vapoenucleation (ThuVEP) and Tm:YAG laser assisted anatomical enucleation (ThuLEP) to men with:
Moderate-to-severe LUTS as alternatives to TURP and holmium laser enucleation (HoLEP).
Recommendation:
Offer ThuVEP to patients receiving:
Anticoagulant or antiplatelet therapy.
Recommendation:
Offer laser resection of the prostate using Tm:YAG laser (ThuVARP) as an alternative to:
TURP.
Recommendation:
Offer ThuVARP to patients receiving:
Anticoagulant or antiplatelet therapy.
Diode Laser MOA
For prostate surgery, diode lasers with a wavelength of 940, 980, 1,318, and 1,470 nm (depending on the semiconductor used) are marketed for vaporisation and enucleation.
ThuVEP and ThuVARP
In the Tm:YAG laser, a wavelength between 1,940 and 2,013 nm is emitted in CONTINUOUS wave mode. The laser is primarily used in FRONT-FIRE applications.
Different applications, ranging from vaporisation (ThuVAP), vaporesection (ThuVARP), and enucleation (ThuVEP vapoenucleation i.e. excising technique/ThuLEP blunt thereby primarily anatomical enucleation with Tm:YAG support) are published.
PUL MOA
The prostatic urethral lift (PUL): novel minimally invasive approach under local or general anaesthesia.
Encroaching lateral lobes are compressed by small permanent suture-based implants delivered under cystoscopic guidance (Urolift®) resulting in an opening of the prostatic urethra that leaves a continuous anterior channel through the prostatic fossa extending from the bladder neck to the verumontanum
Prostatic urethral lift improves ____, ____, and ____ ; however, these improvements are inferior to TURP at 24 months.
IPSS, Qmax and QoL
Recommendation:
Offer Prostatic urethral lift (Urolift®) to men with:
LUTS interested in preserving ejaculatory function, with prostates < 70 mL and no middle lobe.
Intraprostatic injections
The primary mechanism of action of Botulinum Toxin A (BoNT-A) is through the inhibition of neurotransmitter release from cholinergic neurons.
Recommendation:
Do NOT offer intraprostatic Botulinum toxin-A injection treatment to:
Patients with male LUTS.
Results from clinical trials have shown no clinical benefits for BoNT-A compared to placebo for the management of LUTS due to BPO.
Aquablation MOA
AquaBeam uses the principle of hydro-dissection to ablate prostatic parenchyma while sparing collagenous structures like blood vessels and the surgical capsule. A targeted high velocity saline stream ablates prostatic tissue without the generation of thermal energy under real-time transrectal ultrasound guidance. After completion of ablation haemostasis is performed with a Foley balloon catheter on light traction or diathermy or low-powered laser if necessary.
Recommendation:
Offer Aquablation to patients with:
Moderate-to-severe LUTS and prostates between 30-80 mL as an alternative to TURP.
Inform patients about the risk of bleeding and the lack of long-term follow up data.
WAVE ablation (Rezum) MOA
The Rezum system uses radiofrequency power to create thermal energy in the form of water vapour, which in turn deposits the stored thermal energy when the steam phase shifts to liquid upon cell contact. The steam disperses through the tissue interstices and releases stored thermal energy onto prostatic tissue effecting cell necrosis.
Prostatic artery embolisation MOA
Digital subtraction angiography displays arterial anatomy and the appropriate prostatic arterial supply is selectively embolised to effect stasis in treated prostatic vessels.
Recommendation:
Offer prostatic artery embolisation (PAE)* to men with:
Moderate-to-severe LUTS who wish to consider minimally invasive treatment options and accept less optimal objective outcomes compared with transurethral resection of the prostate.
Recommendation:
Perform PAE only in:
Units where the work up and follow up is performed by urologists working collaboratively with trained interventional radiologists for the identification of PAE suitable patients.
Medical treatment algorithm:
No bothersome symptoms
Watchful waiting with or without
education + lifestyle advice
Medical treatment algorithm: Nocturnal polyuria predominant: NO Storage symptoms predominant: NO Prostate vol > 40 mL: NO Education + lifestyle advice +/- alpha1blocker/PDE5i but with residual storage symptoms
Add muscarinic receptor antagonist/beta-3 agonist
Medical treatment algorithm: Nocturnal polyuria predominant: NO Storage symptoms predominant: NO Prostate vol > 40 mL: YES Longterm treatment: NO
Education + lifestyle advice with or without
5α-reductase inhibitor ± α1- blocker/PDE5I
Add muscarinic receptor antagonist/beta-3 agonist
Medical treatment algorithm: Nocturnal polyuria predominant: NO Storage symptoms predominant: NO Prostate vol > 40 mL: YES Longterm treatment: YES
Education + lifestyle advice with or without
5α-reductase inhibitor ± α1- blocker/PDE5I
Medical treatment algorithm:
Nocturnal polyuria predominant: NO
Storage symptoms predominant: YES
Education + lifestyle advice with or without
muscarinic receptor antagonist/beta-3 agonist
Medical treatment algorithm:
Nocturnal polyuria predominant: YES
Education + lifestyle advice with or without
vasopressin analogue
Surgical treatment algorithm:
High-risk: NO
Prostate volume: < 30
TUIP (preferred)
TURP
Surgical treatment algorithm:
High-risk: NO
Prostate volume: 30-80
TURP (preferred) Laser enucleation Bipolar enucleation Laser vaporisation PU lift
Surgical treatment algorithm:
High-risk: NO
Prostate volume: >80
Open prostatectomy (preferred) HoLEP (preferred) Bipolar enucleation (preferred) Laser vaporisation Thulium enucleation TURP
Surgical treatment algorithm:
High-risk: YES
Can have GA: YES
Can stop anticoag: YES
Depends on volume
Surgical treatment algorithm:
High-risk: YES
Can have GA: NO
PU Lift
