Surgical Management of Lower Urinary Tract Symptoms due BPH: AUA guidelines

The American Urological Association has released evidence-based updates to its 2018 clinical guideline on the Surgical Management of Lower Urinary Tract Symptoms (LUTS) Attributed to Benign Prostatic Hyperplasia (BPH).

The goal of this revised guideline is to provide a useful reference on the effective evidence-based surgical management of male lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS/BPH).

Lower Urinary Tract Symptoms, or LUTS, is a group of urinary symptoms caused by an obstruction, abnormality, infection or irritation of the urethra, bladder, bladder neck, urinary sphincter and/or prostate (in men). Although not a normal part of the aging process, LUTS is often diagnosed more often as people age.

BPH is an enlargement of the prostate gland. BPH often results in LUTS. Specific symptoms include a weak urine stream, frequent urination or sudden urges to urinate, not feeling empty after urination and waking up often at night to go to the bathroom. Treatment options include lifestyle changes, medicine and surgery.

"BPH is extremely common. It affects about half of all men between ages 51 and 60 years, and up to 90 percent of men over age 80 years," said J. Kellogg Parsons, MD, MHS, chair of the BPH Guideline Panel. "We believe this revised guideline will provide a useful, evidence-based clinical reference for the surgical management of male LUTS secondary to BPH."

The AUA's guideline update on BPH-related LUTS includes 6 new statements and 10 revisions.

"BPH is extremely common. It affects about half of all men between ages 51 and 60 years, and up to 90% of men over age 80 years," J. Kellogg Parsons, MD, MHS, chair of the BPH Guideline Panel stated in the AUA news release. "We believe this revised guideline will provide a useful, evidence-based clinical reference for the surgical management of male LUTS secondary to BPH."

The guideline was amended as follows:

Guideline statement 1 was amended to include a physical examination for the initial evaluation of patients presenting with bothersome LUTS possibly due to BPH. Supporting text also was added for interpreting the results of urinalysis.

In the initial evaluation of patients presenting with bothersome LUTS possibly attributed to BPH, clinicians should take a medical history, conduct a physical examination, utilize the AUA Symptom Index (AUA-SI), and perform a urinalysis. (Clinical Principle)

Guideline statements 15, 17, 18, and 22 were amended as the retreatment and possibility of treatment failure aspects of these statements are now covered under a new statement 6 under evaluation and preoperative testing. It reads:

Clinicians should inform patients of the possibility of treatment failure and the need for additional or secondary treatments when considering surgical and minimally-invasive treatments for LUTS secondary to BPH. (Clinical Principle)

Statement 16 under prostatic urethral lift (PUL) was amended. This statement now supports PUL use to improve erectile and ejaculatory function and reads as follows:

PUL may be offered to eligible patients who desire preservation of erectile and ejaculatory function. (Conditional Recommendation; Evidence Level: Grade C)

An update to guideline statement 19 on water vapor thermal therapy was made to reflect newly published research. The new statement reads:

Water vapor thermal therapy may be offered to eligible patients who desire preservation of erectile and ejaculatory function. (Conditional Recommendation; Evidence Level: Grade C)

An update to guideline statement 21 pertaining to laser enucleation was made to reflect newly published research. The new statement reads:

Clinicians should consider holmium laser enucleation of the prostate (HoLEP) or thulium laser enucleation of the prostate (ThuLEP), depending on their expertise with either technique, as prostate size-independent options for the treatment of LUTS attributed to BPH. (Moderate Recommendation; Evidence Level: Grade B)

Guideline statement 23 on prostate artery embolization (PAE) was amended to include the following phrase: "PAE for the treatment of LUTS secondary to BPH is not supported by current data and trial designs, and benefit over risk remains unclear."

For further reference log on to:

The full text of the amended clinical guideline is now available online at www.AUAnet.org/Guidelines.