Medical management of LUTS due to benign prostatic hyperplasia: AUA Guideline
USA: The American Urological Association has released a recent guideline on the management of lower urinary tract symptoms attributed to benign prostatic hyperplasia. The first part of the guideline, published in the Journal of Urology, focuses on the initial workup and medical management.
Benign prostatic hyperplasia (BPH) is a histologic diagnosis describing the proliferation of smooth muscle and epithelial cells within the prostatic transition zone. The prevalence and severity of lower urinary tract symptoms (LUTS) in aging men are progressive and impact the health and welfare of society. The revised guideline by Lori B. Lerner, VA Boston Healthcare System, Department of Surgery, West Roxbury, Massachusetts, and team provides a useful reference on effective evidence-based management of male LUTS/BPH.
Key recommendations of the guideline are given below
- In the initial evaluation of patients presenting with bothersome LUTS possibly attributed to BPH, clinicians should obtain a medical history, conduct a physical examination, utilize the International Prostate Symptom Score (IPSS), and perform a urinalysis.
- Patients should be counseled on options for intervention, which can include behavioral/lifestyle modifications, medical therapy and/or referral for discussion of procedural options.
- Patients should be evaluated by their providers 4-12 weeks after initiating treatment (provided adverse events do not require earlier consultation) to assess response to therapy. Revaluation should include the IPSS. Further evaluation may include a post-void residual (PVR) and uroflowmetry.
- Patients with bothersome LUTS/BPH who elect initial medical management and do not have symptom improvement and/or experience intolerable side effects should undergo further evaluation and consideration of the change in medical management or surgical intervention.
- Clinicians should offer one of the following alpha blockers as a treatment option for patients with bothersome, moderate to severe LUTS/BPH: alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin.
- When prescribing an alpha blocker for the treatment of LUTS/BPH, the choice of alpha blocker should be based on patient age and comorbidities, and different adverse event profiles (eg, ejaculatory dysfunction [EjD], changes in blood pressure).
- When initiating alpha blocker therapy, patients with planned cataract surgery should be informed of the associated risks and be advised to discuss these risks with their ophthalmologists.
- For the purpose of symptom improvement, 5-alpha reductase inhibitor (5-ARI) monotherapy should be used as a treatment option in patients with LUTS/BPH with prostatic enlargement as judged by a prostate volume of >30cc on imaging, a prostate-specific antigen (PSA) > 1.5ng/dL, or palpable prostate enlargement on digital rectal exam (DRE).
- 5-ARIs alone or in combination with alpha-blockers are recommended as a treatment option to prevent the progression of LUTS/BPH and/or reduce the risks of urinary retention and need for future prostate-related surgery.
- Before starting a 5-ARI, clinicians should inform patients of the risks of sexual side effects, certain uncommon physical side effects, and the low risk of prostate cancer.
- Clinicians may consider 5-ARIs as a treatment option to reduce intraoperative bleeding and peri- or postoperative need for blood transfusion after transurethral resection of the prostate (TURP) or other surgical intervention for BPH.
- For patients with LUTS/BPH irrespective of comorbid erectile dysfunction (ED), 5mg daily tadalafil should be discussed as a treatment option.
- 5-ARI in combination with an alpha-blocker should be offered as a treatment option only to patients with LUTS associated with demonstrable prostatic enlargement as judged by a prostate volume of >30cc on imaging, a PSA >1.5ng/dL, or palpable prostate enlargement on DRE.
- Anticholinergic agents, alone or in combination with an alpha-blocker, may be offered as a treatment option to patients with moderate to severe predominant storage LUTS.
- Beta-3-agonists in combination with an alpha-blocker may be offered as a treatment option to patients with moderate to severe predominant storage LUTS.
- Clinicians should not offer the combination of low-dose daily 5mg tadalafil with alpha-blockers for the treatment of LUTS/BPH as it offers no advantages in symptom improvement over either agent alone.
- Physicians should prescribe an oral alpha-blocker prior to a voiding trial to treat patients with AUR related to BPH.
- Patients newly treated for AUR with alpha-blockers should complete at least three days of medical therapy prior to attempting trial without a catheter (TWOC).
- Clinicians should inform patients who pass a successful TWOC for AUR from BPH that they remain at increased risk for recurrent urinary retention.
Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART I—Initial Work-up and Medical Management, published in the Journal of Urology.