Optimal Management of BPH – Family MD stream

Pre/post test

  1. Do approximately 90% of men between the ages of 45 and 80 years suffer from some type of lower urinary tract symptom (LUTS)?

a.  Yes

  1. No
  2. Is testosterone the main culprit for the development of Benign Prostatic Hypertrophy (BPH)?
  3. Yes

b.  No

  1. Does the size of the prostate correlate with the severity of LUTS?
  2. Yes

b.  No

  1. Is urgency, frequency and urge incontinence considered storage lower urinary tract symptoms (LUTS)?

a.  Yes

  1. No
  2. Do most men with lower urinary tract symptoms discuss their symptoms with their primary care physician?
  3. Yes

b.  No

  1. Is the digital rectal exam a mandatory component for diagnosing BPH?

a.  Yes

  1. No
  2. Does PSA have a role in the assessment of selected patients with BPH?

a.  Yes

  1. No
  2. Should watchful waiting for at least 3 months be the first treatment option for all patients with BPH?
  3. Yes

b.  No

  1. Is combination therapy with an alpha blocker and 5 alpha-reductase inhibitor more effective than either therapy alone?

a.  Yes

  1. No
  2. Is saw palmetto a recommended option for the treatment of BPH?
  3. Yes

b.  No

Pre-Course Survey

  1. How comfortable do you feel assessing lower urinary tract symptoms in men over the age of 50? (1= not at all comfortable, 5 = very comfortable)
  2. How would you rate your ability to diagnose benign prostatic hyperplasia based on current best practice guidelines? (1 Diagnose with significant difficulty, 5 Diagnose with ease)
  3. How comfortable do you feel selecting the most appropriate BPH treatment based on current clinical practice guidelines? (1 not at all comfortable, 5 very comfortable)
  4. How comfortable do you feel discussing the pros and cons of each BPH treatment option with your patients? (1 not at all comfortable, 5 very comfortable)
  5. How would you rate your proficiency on the complete management of your patients with BPH? (1= low, 5 = very high)

Meet our Patient

Robert S. (64 years old) is in your office to discuss his lower urinary tract symptoms (LUTS). When you review his chart you see the following notes:

Robert S. 64 years old
Current Medications
·  Perindopril 4 mg daily
·  Amlodipine 5 mg daily
Urology Specific notes:
·  Presented with LUTS symptoms approximately 3 months ago
·  Today’s IPSS score of 17
o  Storage and voiding symptoms
o  QOL score is 5
·  Last PSA = 2.4 ng/mL
·  Urinalysis normal
·  DRE 3 months Ago– Moderate enlargement, smooth, non-tender prostate
·  No family history of prostate cancer
·  Both father and older brother have had LUTS associated with BPH

Case Challenge

1.  Which of the following is the MOST appropriate action for this patient?

  1. Do nothing he has little bother from symptoms so no treatment is indicated
  2. Discuss bother, BPH and different treatment options
  3. Refer to urologist to rule out prostate cancer
  4. Refer to urologist to manage BPH symptoms

2.  Should you be worried about his PSA reading?

  1. Yes, he should be referred to a urologist for a prostate cancer assessment

b.  No, his reading is not high, he has no risk factors for prostate cancer and is most likely associated with BPH

Introduction

Lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) are commonly seen in clinical practice. One internet survey of US, UK and Swedish patients ≥ 40 years of age found that close to 71% of men had at least one LUTS and about half reported LUTS from multiple symptom groups (voiding, storage or postmicturition).1 Another study estimated that 90% of men between 45 and 80 years of age suffer from some type of LUTS.2 Benign prostatic hyperplasia (BPH) is the primary cause of lower urinary tract symptoms (LUTS) in older men. It affects: 3

·  Approximately 42% of men aged 51-60 years

·  Over 70% of men 61-70 years

·  Almost 90% of men aged 81 to 90.

With BPH affecting such a large portion of men, it is important that each clinician feel comfortable with the evidence based management of the condition. Primary care physicians are ideally placed for case detection of BPH, patient assessment and initiating management strategies.

Learning Objectives

Upon successful completion of this program the physician will be better able to:

  1. Implement the evidence based assessment and diagnosis of LUTS secondary benign prostatic hyperplasia (BPH) in clinical practice
  2. Describe the impact of BPH LUTS on the quality of life of patients, and the role of treatment in symptom improvement and disease progression
  3. Prescribe and tailor treatment options for patients based on BPH symptoms
  4. Discuss the level of evidence to support each treatment option for BPH symptoms
  5. Discuss appropriate follow-up and shared BPH care between family physicians and urologists

Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is defined as a histologic diagnosis that refers to the proliferation of smooth muscle and epithelial cells within the prostatic transition zone.2 This hyperplasia occurs in nodular compression, primarily in the transitional zone of the prostate.4 This leads to prostate gland enlargement which may cause lower urinary tract symptoms (LUTS).

Etiology of BPH

The exact cause of BPH is unknown, but is thought to be primarily hormonal based.3 The testes are crucial in the development of BPH, where castrated men (surgically or chemically) do not develop BPH.4 Testosterone itself is not thought to be the culprit hormone to BPH development but rather the hormone dihydrotestosterone (DHT).4 This hormone is produced through the conversion of testosterone by the enzyme 5 alpha-reductase type 2 in the stromal cells of the prostate.4 Here are some key facts regarding DHT:4

·  DHT is mainly synthesized in the prostate

·  In the serum, the testosterone level is higher than DHT (ratio testosterone:DHT > 10). The ratio is reversed in the prostate

·  DHT binds more tightly to the androgen receptors in the stromal cells than testosterone

·  Testosterone levels decrease as a man ages but DHT levels do not, thus leading to the altered cell growth dynamics in the prostate

·  DHT and the enzyme 5 alpha-reductase are crucial to the continual hyperplasia in the prostate

Risk factors for BPH

Family history of BPH and increasing age are thought to be the primary risk factor for the development of BPH.3 Sexual activity and alcohol have not proven to contribute to BPH development.3 Certain races such as people of African descent were thought to be at significant risk for the development of BPH but several trials question African race as a risk factor for BPH.5,6

There is increasing research on the role of metabolic syndrome risk factors and the development of BPH. A review of evidence suggests that diabetes, hypertension, ischemic heart disease, insulin resistance and dyslipidemia are possible risk factors for BPH.7 In the recent American Urological Association (AUA) BPH guidelines the possible link between obesity, metabolic syndrome and BPH was viewed as a high priority for future research.2

Symptoms of BPH

The growth of the prostatic tissue starts to compress the prostatic urethra. This compression leads to the development of many of the lower urinary tract symptoms (LUTS) associated with the condition. LUTS include storage and/or voiding disturbances are common in aging men.

·  Storage symptoms are experienced during the storage phase of the bladder and include daytime frequency and nocturia.2

·  Voiding symptoms are experienced during the voiding phase (e.g. urinary hesitancy, slow stream).2

Approximately one half of patients with BPH experience LUTS, of which urinary hesitancy, weak stream and nocturia are the most common symptoms.3 Table 1 lists the most common storage and voiding LUTS of BPH. 8

BPH is a progressive condition BPH may progress in the form of increased prostate volume, reduction in maximum urinary flow rate and increased risk of acute urinary retention and surgery.9

Table 1 – Lower Urinary Tract Symptoms (LUTS) seen in benign prostatic hyperplasia3
Storage / Voiding / Other
·  Urgency
·  Frequency
·  Nocturia
·  Urge incontinence / ·  Hesitancy
·  Poor flow
·  Intermittency
·  Straining
·  Dysuria (painful urination)
·  Incomplete emptying / ·  Postvoid dribble

Patient Perceptions of BPH

Most cases of BPH are asymptomatic. Among those with symptoms, many men will not seek treatment for the symptoms of BPH, even though their symptoms are often moderate to severe and lead to a decrease in the quality of life, anxiety and depression.10 One study evaluated the reasons for not discussing their symptoms with their physician.11 This survey found that 39% of men did not seek treatment from their doctor, despite having moderate to severe BPH.11 Fear of prostate cancer, the severity of symptoms, bother, interference with activities, and decreased quality of life are the main reasons men will seek treatment for BPH.

Some of the reasons that men with symptoms cite for not seeking care include:11

·  Acceptance that LUTS are a natural part of aging

·  Symptoms are not causing significant bother

·  Stigma associated with symptoms such as dribbling and urgency

·  Fear of cancer or surgery and its associated side effects.

Among patients who consulted their family physician, their LUTS were the main reason to initiate the discussion, but several other factors were much more likely to motivate a patient to seek treatment:11

·  Social influences including being advised by others (e.g. spouse) to see a doctor (odds ratio (OR) = 5.5)

·  Belief that the physician could improve their condition (OR =2.7)

·  Information in the mass media about symptoms (OR = 2.1)

Case detection of LUTS is an important component to diagnosing and management of BPH. All men over the age of 50 years should be screened for LUTS by asking the one question (or similar screening questions)in figure 1 during a physical exam or system review.10

If the patient answers no to any problems urinating, then no further questioning or assessment is required. If the patient answers yes, then the clinician is encouraged to investigate further (see next section). Through appropriate questioning, clinicians can help identify patients that have significant symptoms but fail to initiate the discussion with their family physician regarding their LUTS.

Figure 1 – Case Detection Question for LUTS and BPH


* - Urinating can be replaced with any of the following terms depending on the patient: peeing, voiding or passing water

Case Challenge

You mention to Robert that you think he has BPH. You decide to run through a full a diagnostic evaluation for BPH.

1.  Which of the following test is mandatory for the diagnosis of BPH?

a.  Urinalysis

  1. IPSS completion
  2. PSA
  3. Serum creatinine

2.  Which of the following symptoms would suggest a referral to an urologist is appropriate?

  1. Medium size prostate
  2. Any PSA level > 2.0 ng/mL

c.  Previous urological surgery

  1. All of the above

3.  When treating BPH which of the following plays the largest factor in determining the need for treatment?

  1. PSA score
  2. IPSS/AUA-SI score

c.  Patient’s level of bother

  1. Prostate size

Diagnostic Evaluation

Current Canadian, American and Australian clinical practice guidelines recommend physicians tailor their assessment based on mandatory and optional testing. The mandatory tests for all men with LUTS include a patient history, physical exam, urinalysis and a recommended test that could be performed in selected men with LUTS is serum PSA. 12 Mandatory and Recommended Tests

Patient History

A medical history should be performed to clearly establish the symptoms and exclude other conditions.3 A focussed patient history should be obtained. Table 2 lists some areas to focus upon when conducting a medical history. Table 3 lists other conditions that could be causing LUTS. Table 4 lists medications that could be contributing to LUTS.

Table 2 – Suggested areas for clinicians to assess when conducting a patient history12,13
·  Previous surgical procedures (especially any urological procedures)
·  Any previous trauma to the genitourinary tract
·  Sexual function history
·  Medications currently taken
·  Family history of BPH and prostate cancer
Table 3 – Differential diagnosis of LUTS3
·  Bladder cancer
·  Prostate cancer
·  Prostatitis
·  Bladder stones
·  Interstitial cystitis
·  Radiation cystitis
·  Urinary tract infection / ·  Diabetes mellitus
·  Parkinson’s disease
·  Primary bladder neck hypertrophy
·  Congestive heart failure
·  Lumbosacral disc disease
·  Multiple sclerosis
·  Nocturnal polyuria
Table 4 - Medications that may Contribute to Lower Urinary Tract Symptoms3
Medications / Notes
Antihistamines / ·  Decreased parasympathetic tone
Decongestants / ·  Increased sphincter tone via alpha-adrenergic receptor stimulation
Diuretics / ·  Increased urine production
Opiates / ·  Impaired bladder contractility
Tricyclic Antidepressants / ·  Anticholinergic effects

Assessment of LUTS and Symptom Bother

One of the most important components of the patient history is the assessment of the type, severity and duration of LUTS. The International Prostate Symptom Score (IPSS) and the American Urological Association Symptom Index (AUA-SI) are tools that can aid in the evaluation and quantification of a patient’s symptom severity.3 Table 5 lists the IPSS.

Table 5 – International Prostate Symptom Score (IPSS)
Question / Not at all / Less than 1 time in 5 / Less than half the time / About half the time / More than half the time / Almost always
Incomplete Emptying
1.  Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? (S) / 0 / 1 / 2 / 3 / 4 / 5
Frequency
2.  Over the past month, how often have you had to urinate again less than two hours after you finished urinating? (S) / 0 / 1 / 2 / 3 / 4 / 5
Intermittency
3.  Over the past month, how often have you found you stopped and started again several times when you urinated? (V) / 0 / 1 / 2 / 3 / 4 / 5
Urgency
4.  Over the last month, how difficult have you found it to postpone urination? (S) / 0 / 1 / 2 / 3 / 4 / 5
Weak Stream
5.  Over the past month, how often have you had a weak urinary stream? (V) / 0 / 1 / 2 / 3 / 4 / 5
Straining
6.  Over the past month, how often have you had to push or strain to begin urination? (V) / 0 / 1 / 2 / 3 / 4 / 5
None / 1 time / 2 times / 3 times / 4 times / 5 or more times
Nocturia
7.  Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? (S) / 0 / 1 / 2 / 3 / 4 / 5
Total Symptom Score:_____
·  Score 0-7 = Mild
·  Score 8-19 = Moderate
·  Score 20-35=Severe
Quality of life Assessment
If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?
(scored on a scale of 0 to 6 points (delighted to terrible)

(S) – Storage symptoms; (V) – Voiding symptoms