Transcript capslide - Urology Information Site

Advances in the Management
of BPH
Mr C Dawson
Consultant Urologist
Edith Cavell Hospital
Peterborough
Advances in the Management
of BPH
Mr C Dawson
Consultant Urologist
Fitzwilliam Hospital
Peterborough
The Scale of the Problem
Moderate to severe Lower Urinary Tract
Symptoms (LUTS) occur in 25% of men
over 50 years, and the incidence rises with
age
 Approximately 90% of men will develop
histological evidence of BPH by 80 years of
age

The Scale of the Problem
Increasing because:
 Men are living longer
 Proportion of Men over 50 years will
increase
 Men are better informed about health
matters
Difficulties in Diagnosis and
Management
The symptoms of BPH are the same as
those of early Prostate Cancer
 Confirmation of the presence of prostate
cancer may be difficult
 The need to treat (proven) cancer may not
always be clear cut

Understanding Lower Urinary
Tract Symptoms (after Abrams, Bristol, UK)
Detrusor Instability
Bladder Hypersensitivity
Storage Symptoms
 Frequency
 Nocturia
 Urgency
 Urge incontinence
 Bladder Pain
Bladder Outlet Obstruction
Detrusor Failure
Voiding Symptoms
 Slow stream
 Intermittent flow
 Hesitancy
 Straining
 Terminal dribble
Physical Signs
May be few
 Look for obvious uraemia
 Palpate for full bladder
 Examine urethral meatus and palpate
urethra for stricture
 DIGITAL RECTAL EXAMINATION
(DRE) !!

Investigations for BPH
Urea and electrolytes if clinically indicated
 PSA (should we counsel patients?)
 Ultrasound urogram
 Flow rate (if you have access)
 IPSS

IPSS
A word about Prostate Cancer
No symptoms specific for early prostate
cancer
 Presenting symptoms are therefore those of
BPH
 Biopsy of the prostate should be performed
in those with abnormal DRE, or PSA above
age-specific reference range

Prostate Specific Antigen
Single-chain glycoprotein of 240 aa
residues and 4 carbohydrate side chains
 Physiological role in lysis of seminal
coagulum
 Prostate specific, but NOT cancer specific

Prostate Specific Antigen
In addition to prostate cancer, an elevated level may
be found in
 Increasing age
 Acute urinary retention / Catheterisation
 after TURP / Prostate Biopsy
 Prostatitis
 BPH
A reduced level may be found in patients treated
with Finasteride
The Problem with PSA
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Men with Prostate Cancer may have a normal
PSA
Men with BPH or other benign conditions may
have a raised PSA
May not even be prostate-specific!
What to do with men with a PSA of 4-10 ng/ml
PSA = Persistent Source of Anxiety?
Refinements in the use of PSA
PSA density
 PSA Velocity
 Age-Specific PSA

40-49 Years old
50-59 Years old
60-69 Years old
70-79 Years old

<2.5ng/ml
<3.5ng/ml
<4.5ng/ml
<6.5ng/ml
Free:Total PSA ratio (<0.15 strongly
suggests possibility of Ca Prostate)
Prostate Specific Antigen
Possibly
Some
Attributes
The Management of BPH

Advances in the
Management of
BPH
New treatment modalities for BPH
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-blocker therapy (including selective blockers of 1a receptors)
5- -reductase inhibitors - Finasteride (Proscar)
Minimally invasive Techniques
–
–
–
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Transurethral Microwave Thermotherapy (TUMT)
Transurethral Needle ablation (TUNA)
Transrectal high-intensity focused ultrasound (HiFU)
Transurethral electrovaporisation (TUVP)
Pharmacotherapy for BPH
Alpha-blockers remain an important therapy
 Selective -1a receptor blockers may have
fewer side effects

Alpha blocker therapy
Pharmacotherapy for BPH

Finasteride (Proscar) - PLESS study has
confirmed that men with large prostates
(>40cc), taking long-term therapy, less
likely to develop acute retention, or require
surgical intervention
Minimally invasive therapies
High energy TUMT, and TUNA, have
proven clinical efficacy between that of
drug therapy and TUVP or laser therapy
 HiFU currently requires GA, is costly and
time consuming, and appears unlikely to be
popular at present
 The subjective response after MITs and
TURP appear similar, but objective results
superior for TURP

Surgical Therapies
TURP still the gold standard therapy, with
which all other therapies must be
considered
 Laser therapy
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– expensive to set up
– Significantly reduced blood loss
– Catheter may be required post operatively

Open Prostatectomy rarely required
ECH Urology Department Guidelines
for the Management of BPH
Produced after discussion between working
party of General Practitioners and
Consultants
 Agreed within the department of Urology

Protocol for the management of
BPH
GP Assesses Patient
History
IPSS Score
DRE
U+E and PSA
Flow rate and Residual volume if possible
Options
Referral to Urology Department
Management by GP
(See next slide)
Normal DRE and PSA
Abnormal DRE and PSA
Eligible for Shared Care
Outpatient appt with
Prostate Clinic
Consultant
Protocol for the management of
BPH
IPSS Score
Management
Mild
IPSS<7
Flow Rate >15 mls/s
Resid vol < 100 mls
Watchful Waiting
Moderate
IPSS 7-20
Flow rate < 15mls/s
Resid vol <200 mls
alpha-blockers:
Refer if no improvement
Severe
IPSS > 20
Flow rate < 10 mls/s
Resid vol > 200 mls
Refer to the Urology
Department
Future perspectives for the
management of BPH
Much more emphasis on Quality of Life
 Minimally invasive therapies are improving
and may yet challenge the superiority of
TURP

Conclusions - BPH
Remains an important cause of patient
morbidity
 Correct approach to assessment is important
 Many men may have their symptoms relieved
by alpha blocker therapy or Finasteride, which
has also been shown to reduce the likelihood
of surgery or acute urine retention
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Conclusions - BPH
A large variety of MITs exist for BPH who
fail drug therapy, but for most patients the
gold standard surgical procedure remains
TURP
 The next few years will see many more
techniques available to challenge the
position of TURP
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Thank you for your attention