Technically, BPH -> BPE -> BOO -> LUTS. BPH is a histologic diagnosis. Therefore, a patient presenting with LUTS may be secondary to BOO, caused by BPE from BPH.
Evaluation of LUTS, from Campbell's
Evaluation/Workup
History
- Assess baseline symptoms (voiding + storage), use AUASS
- Other conditions causing LUTS: DM, neurologic, CKD/CHF, OSA, cancer
- Assess fluid, caffeine intake
- Consider PSA check after discussing risks/benefits and need for further workup
Clinic tests
- DRE: prostate cancer PPV 6-33%, poor estimate of prostate size
- PVR: no standardized definition or unified cutoff, questionable association with developing acute retention
- Uroflow: inaccurate if < 125-150mL, cannot distinguish BOO from DUA, consider 15mL/s a reasonable cutoff
- Cystoscopy: consider for gross hematuria, history bladder cancer, history recurrent UTIs or urethral injury, history prior urethral surgery, and prior to surgical planning
- UDS: recommended if prior surgical therapy, unable to void > 150mL, PVR > 300mL, concern for neurologic disease, prior pelvic surgery, age > 80 or < 50 and predominantly voiding symptoms
BPH Labs
- UA: may be helpful for identifying UTI or hematuria
- Cytology: consider if severe storage symtpoms, dysuria, and smoking history
- PSA: test if cancer diagnosis will change BPH management (life expectancy > 10yrs)
- Renal fxn: check if considering surgical management (increased postop risk)
Treatment of LUTS, from Campbell's
Non-Surgical Managment
Conservative Management
- Watchful waiting: reasonable for mild symptoms, check symptoms annually
- Fluids: maintain 1.5-2L intake (adjust as needed), decrease caffeine/alcohol
- Restrict fluids 2-4hrs before bed
- Behavioral: timed voiding, double voiding, "urethral milking" (for postvoid dribbling)
- Constipation: avoid.
Alpha-blockers
- Receptor blockade leads to smooth muscle relaxation at bladder neck, prostate, and proximal urethra
- Improves symptom scores and uroflow parameters
- Terazosin: 2-5mg QHS, dizziness (14-17%), asthenia (5-13%) headache (5-13%), hypotension (2%)
- Doxazosin: 2-8mg QHS, dizziness (5%), headache (5%)
- Alfuzosin: 10mg QHS, dizziness (12%), asthenia (5%), hypotension (3%), CV effects (10%)
- Tamsulosin: uroselective, 0.4-0.8mg QHS, dizziness (3-15%), asthenia (24%), headache (5-16%), retrograde ejaculation (1-18%), CV effects (9%)
- Silodosin: uroselective, 8mg QHS, retrograde ejaculation (10-14%), dizziness (8%), headache (3%)
- Terazosin and doxazosin cause first-dose hypotension, requiring dose titration
- CV effects: alfuzosin increases CV effects, whereas tamsulosin/silodosin do not interact with cardiac medications
- No proven effect on erectile function or libido, but tamsulosin/silodosin cause retrograde ejaculation and orgasmic impairment in ~17%
- Intraoperative floppy iris syndrome (IFIS): occurs during cataract surgery after a-blocker exposure, can occur even after drug discontinuation, tamsulosin (30-88%), alfuzosin (15-70%), doxazosin (2-45%)
5-a reductase inhibitors
- Prevents conversion of T to DHT, inhibiting prostate growth
- Decreases risk of urinary retention or need for prostate surgery
- Only indicated if prostate > 40g and PSA > 1.5
- Finasteride: Type 2 selective, 5mg daily
- Dutasteride: nonselective, 0.5mg daily
- Takes 6 months for full effect
- PSA levels decrease by 50%
- Potentially increases high-risk prostate cancer
- Side effects: decreased libido (4-5%), ejaculatory dysfunction (4%), erectile dysfunction (6%), gynecomastia/breast tenderness (0.5-1%)
Anticholinergics
- Antagonism of bladder muscarinic receptors results in bladder relaxation, decreasing bladder spasms
- Most beneficial in patients with high storage symptom scores, high flow rate, low PVR
- Increases PVR by an average of 25mL
- Options: darifenacin 7.5-15mg QD, fesoterodine 4-8mg QD, oxybutynin IR 2.5-5mg 3-4x daily, oxybutynin ER 5-15mg QD, solifenacin 5-10mg QD, trospium 60mg QD or 20mg BID
- Side effects: dry mouth (≥ 16%), constipation (≥ 4%), dizziness (≥ 5%), and cognitive dysfunction
B3-Agonist - Mirabegron
- Stimulates bladder relaxation
- Dosing: 25mg QD, titrate up to 50mg
- Increases PVR by average 30mL
- Side effects: nasopharyngitis (3-6%), headache (2-3%), hypertension (10-12%)
Phosphodiesterase Type 5 inhibitors
- May increase oxygenation of tissue, relax bladder neck and prostate smooth muscle, decrease stromal proliferation and inflammation
- Tadalafil 5mg is currently the only option recomended for LUTS
- Side effects: headache (13%), dyspepsia (7%), flushing (7%)
Phytotherapy
- Different extracts and preparations have widely variable amounts of "active" ingredients
- All evidence is based on in vitro studies, no good long-term clinical evidence exists that phytotherapy is beneficial
Surgical Management
Indications for Surgery
- Hematuria: finasteride has proven benefit for decreasing further episodes, confirm BPH as cause with hematuria workup, can consider BPH surgical management at time of clot evacuation
- Bladder stones: can consider medical management after removal of bladder stones
- Recurrent UTIs: may be secondary to incomplete emptying
- Urinary retention: idiopathic vs iatrogenic, up-front surgery not recommended, 60% pass first voiding trial, up to 80% have another retention episode within 6 months
- Upper tract injury: not necessary to screen prior to interventions, if secondary to BOO then place catheter and reassess, bladder wall hypertrophy may cause persistent obstruction and require stenting
- Bladder diverticulum: not a clear indication unless related UTIs or bladder decompensation
Choosing the right surgery
- Prostate size: prostates > 80-150g benefit from HOLEP or simple prostatectomy
- Anticoagulation: consider PVP/KTP, HoLEP to minimize bleeding
- Median lobe: urolift less efficacious
- Other considerations: risks/benefits, prior surgeries, surgeon experience, patient preference
- Patient should undergo cystoscopy + sizing to assess best treatment option
- Consider urodynamics prior to surgery if unclear cause of symptoms
- See the separate page for info about TURP, UroLift, PVP, and TUIP
Clinical scenario: patient with > 100g prostate, with(out) urinary retention
- RALP has increased risk for incontinence due to bladder neck reconstruction
- RALP age cutoff 70 (with exceptions), whereas RASP has no age cutoffs
- RASP + XRT may be better option for continence and prostate cancer than RALP
- MRI prostate, PSA, and biopsy will not change need for RASP (or other outlet procedure)
- Could perform biopsy at time of RASP
- Can consider XRT or other adjuvant therapies based on post-RASP PSA
- THEREFORE: in patient with 100+g prostate, can consider up-front RASP with truncated prostate cancer workup - do not need to delay treatment of retention for prostate cancer
Other surgical risks
- Infection: sepsis 2.3%, consider longer course than OR prophylaxis if indwelling catheter
- Incidental cancer diagnosis: if PSA < 4, cancer diagnosed in 1/382 TURPs (uncommon)
References
- AUA Core Curriculum
- Capogrosso, P., A. Salonia, and F. Montorsi. "Evaluation and Nonsurgical Management of Benign Prostatic Hyperplasia." Campbell-Walsh Urology 12 (2020).
- Helo, S., C. Welliver, and K. McVary. "Minimally Invasive and Endoscope Management of Benign Prostatic Hyperplasia." Campbell-Walsh Urology 12 (2020).
- Parsons, J. Kellogg, et al. "Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline amendment 2020." The Journal of urology 204.4 (2020): 799-804.