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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)

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)

Relevant studies

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.