Basic Management: BPH

From: http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/bph-management/chap_1_GuidelineManagementof(BPH).pdf

Basic Management
The algorithm describing basic management of BPH/LUTS classifies diagnostic tests as either recommended or optional. A "recommended test" should be performed on every patient during the initial evaluation whereas an "optional test" is a test of proven value in the evaluation of select patients. In general, optional tests are performed during a detailed evaluation by a urologist.
If the initial evaluation demonstrates the presence of LUTS associated with results of a digital rectal exam (DRE) suggesting prostate cancer, hematuria, abnormal prostate-specific antigen (PSA) levels, recurrent infection, palpable bladder, history/risk of urethral stricture, and/or a neurological disease raising the likelihood of a primary bladder disorder, the patient should be referred to a urologist for appropriate evaluation before advising treatment (Figure 1.1 in Appendix A7). Baseline renal insufficiency appears to be no more common in men with BPH than in men of the same age group in the general population.
Not Recommended: The routine measurement of serum creatinine levels
is not indicated in the initial evaluation of men with LUTS secondary to BPH.
[Based on review of the data and Panel consensus.]
When initial evaluation demonstrates the presence of LUTS only, with or without some degree of nonsuspicious prostate enlargement, if the symptoms are not significantly bothersome or if the patient does not want treatment, no further evaluation is recommended. The patient should be reassured and can be seen again if necessary. This recommendation is based on the opinion that patients with nonbothersome LUTS are unlikely to experience significant health problems in the future due to their condition.
In patients with bothersome symptoms, it is now recognized that LUTS has a number of causes that may occur singly or in combination. Among the most important are BPO, overactive bladder, and nocturnal polyuria. The physician can discuss with the patient treatment alternatives based on the results of the initial evaluation with no further tests being needed (See Figure 1.1 Recommended Tests in Appendix A7). There should be a discussion of the benefits and risks involved with each of the recommended treatment alternatives (e.g., watchful waiting, medical, surgical, or minimally invasive surgical treatments). Then the choice of treatment is reached in a shared decision-making process between the physician and patient.
If the patient has predominant significant nocturia and is awakened two or more times per night to void, it is recommended that the patient complete a frequency volume chart for two to three days. The frequency volume chart will show 24-hour polyuria or nocturnal polyuria when present, the first of which has been defined as greater than three liters total output over 24 hours. In practice, patients with bothersome symptoms are advised to aim for a urine output of one liter per 24 hours. Nocturnal polyuria is diagnosed when more than 33% of the 24-hour urine output occurs at night. Nocturia should be managed according to the algorithm in Figure 1.1 in Appendix A7 in that fluid intake should be reduced; other treatments, such as desmopressin, can also be considered. If symptoms do not improve sufficiently, these patients can be managed similarly to those without predominant nocturia.
If the patient has no polyuria and medical treatment is considered, the physician can proceed with therapy by focusing initially on modifiable factors such as concomitant drugs, regulation of fluid intake (especially in the evening), lifestyle (increasing activity) and diet (avoiding excess of alcohol and highly seasoned or irritative foods).14 If pharmacological treatment is necessary, it is recommended that the patient be followed to assess treatment success and possible adverse events. The time from initiation of therapy to treatment assessment varies according to the pharmacological agent prescribed. An interval of two to four weeks is recommended for alpha-blockers and at least a three-month interval is recommended for 5-ARIs.
If treatment is successful and the patient is satisfied, once yearly follow-up should include a repeat of the initial evaluation. The follow-up strategy will allow the physician to detect any changes Copyright ©2010 American Urological Association Education and Research, Inc.® 7
that have occurred -- more specifically, if symptoms have progressed or become more bothersome, or if a complication has developed that requires surgery.

Detailed Management
If the patient’s LUTS are being managed by a primary care giver and the patient has persistent bothersome LUTS after basic management, then a urologist should be consulted. The urologist may use additional testing beyond those recommended for basic evaluation (Figure 1.2 in Appendix A7).
If drug therapy is considered, decisions will be influenced by coexisting overactive bladder symptoms and prostate size or serum PSA levels. If there are coexisting BOO and overactive bladder symptoms then the patient can be treated with combination alpha-blocker and anticholinergic therapy. When BOO symptoms predominate, alpha-adrenergic blocking agents are the first treatment of choice for LUTS due to BPH. However, alpha-blockers alone, 5-ARIs alone, and/or combination alpha-blocker and 5-ARI therapy have shown the most efficacy when the prostate is enlarged as assessed by PSA levels, transrectal ultrasound (TRUS) or on DRE (Figure 1.2 in Appendix A7). As always, the decision for choice of therapy should be decided in concert with the patient’s wishes and concerns.
If storage symptoms predominate, an overactive bladder due to idiopathic detrusor overactivity is the most likely cause if there is no indication of BOO from flow study. The treatment options of lifestyle intervention (fluid intake alteration), behavioral modification and pharmacotherapy (anticholinergic drugs) should be discussed with the patient. It is the expert opinion of the Panel that some patients may benefit using a combination of all three modalities. Should improvement be insufficient and symptoms severe, then newer modalities of treatment such as botulinum toxin and sacral neuromodulation can be considered. The patient should be followed to assess treatment success or failure and possible adverse events according to the section on basic management above.
Interventional Therapy
If the patient elects interventional therapy and there is sufficient evidence of obstruction, the patient and urologist should discuss the benefits and risks of the various interventions. Transurethral resection is still the gold standard of interventional treatment but, when available, new interventional therapies could be discussed. The techniques accepted for clinical use are summarized below.
If the patient's condition is not sufficiently suggestive of obstruction (e.g., peak urinary flow (Qmax) >10 mL/sec) pressure flow studies are optional as treatment failure rates are somewhat higher in the absence of obstruction. If interventional therapy is planned without clear evidence of the presence of obstruction, the patient needs to be informed of possible higher failure rates of the procedure.
Treatment Alternatives
Standard: Information : see link http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/bph-management/chap_1_GuidelineManagementof(BPH).pdf