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Diagnosis, management, and referral of men with lower urinary tract symptoms due to benign prostatic hyperplasia

This management algorithm was developed by a multidisciplinary expert panel: Rees J et al with the support of a grant from NeoTract, Inc. See bottom of page for full disclaimer.

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Management algorithm for men with LUTS due to BPH

  • Lower urinary tract symptoms (LUTS) can include voiding, storage, and/or post-micturition symptoms
  • Benign prostatic hyperplasia (BPH) is one of the most common causes of male LUTS; this can lead to benign prostate enlargement (BPE) and bladder outlet obstruction
  • Men with BPH typically experience voiding symptoms (e.g. weak or intermittent urinary stream, straining, hesitancy, terminal dribbling, and incomplete emptying) but may also report:
    • storage symptoms (e.g. urgency, frequency, urgency incontinence, and nocturia)
    • post-micturition symptoms (most commonly post-micturition dribbling)
  • This algorithm provides advice on the management of LUTS due to BPH:

Initial assessment

  • A urine dipstick test should be offered to all men with LUTS to detect urinary blood, glucose, protein, leucocytes, and/or nitrites
  • A prostate-specific antigen (PSA) test should be offered if:
    • LUTS are suggestive of bladder outlet obstruction secondary to BPE or
    • the prostate feels abnormal on digital rectal examination (DRE) or
    • the patient is concerned about prostate cancer
  • An International Prostate Symptom Score (IPSS) questionnaire could be used to assess baseline symptom severity so that the effects of subsequent treatment(s) can be monitored
  • Men with bothersome LUTS, particularly those with predominately storage symptoms, could be asked to complete a urinary frequency volume chart (FVC)
  • PDFs of the IPSS questionnaire and FVC can be downloaded from: www.primarycareurologysociety.org

Urgent referral

  • Local care pathways should be followed, if any of the following signs/symptoms are present: haematuria, significantly raised creatinine, raised PSA, nocturnal enuresis, recurrent urinary tract infections (UTIs), palpable bladder, or abnormal DRE

Conservative management

  • Men who are undergoing conservative management should be advised to return if LUTS worsen
  • Use of herbal supplements cannot be recommended due to lack of supportive evidence

Fluid intake

  • Men should be advised on fluid intake; including:
    • reducing intake of fluids containing caffeine, alcohol, and artificial sweeteners, and carbonated drinks
    • avoiding insufficient or excessive fluid intake (1.5–2.0 litres/day is ‘about right’ for most men)
    • reducing intake of fluids in the evening if nocturia is present (with a recommendation that drinks should be kept to a minimum 4 hours before bedtime)

Urethral milking

  • Post-micturition dribble can be reduced by drawing the tips of the fingers behind the scrotum and then pushing up and forward to expel the pooled urine

Initiation and side-effects of drug therapy

  • Drug therapy should only be offered to men with bothersome LUTS when conservative management options have been unsuccessful or are not appropriate
  • When starting a new therapy, counselling on possible side-effects should be given, as the likelihood/nature of these may influence treatment preferences and compliance
  • In men with predominantly mixed LUTS (i.e. voiding, storage, and/or post-micturition symptoms) and erectile dysfunction (ED), a phosphodiesterase type-5 (PDE-5) inhibitor to treat both LUTS and ED may be considered
  • Common side-effects of each drug therapy are listed below:
    • alpha-blockers—ejaculatory dysfunction and dizziness/postural hypotension
    • 5-alpha reductase inhibitors—fatigue, breast tenderness and swelling, ED, and loss of libido
    • anticholinergics—dry mouth, constipation, and blurred vision
    • beta-3 agonists—tachycardia and UTIs
    • PDE-5 inhibitors—headache, dyspepsia, back pain, facial flushing, and nasal congestion

Referral

  • Onward referral should only be considered after failure of medical management (inadequate symptom control or medicines not tolerated)
  • GPs should understand the treatment options available in order to appropriately refer patients and manage their expectations regarding potential surgical options
  • The most appropriate surgical option will be dependent on the patient and the availability of surgical options in the geographical area:
  • minimally invasive options may be particularly suitable for men who want to preserve sexual function and those at high risk of complications during general anaesthesia
  • invasive options, such as transurethral resection of the prostate (TURP) or holmium laser enucleation of the prostate (HoLEP), may be more suitable for men with severe LUTS 

Minimally invasive surgery

  • Prostatic urethral lift:
    • minimally invasive treatment—implants (usually 2–4) are placed under local or general anaesthetic to retract prostate tissue and improve bladder outflow
    • no cutting or removal of tissue
    • usually performed as a day case without the need for a post-operative catheter
    • suitable for patients of all ages who prefer a minimally invasive, catheter-free procedure, or wish to preserve sexual function
    • not advised for men with prostates >100 cc or with predominantly obstructing median lobe of prostate

Traditional surgical approaches

  • Risk of retrograde ejaculation with all traditional surgical approaches
  • Fluid saline is used instead of glycine for irrigation in HoLEP and PVP, meaning there is no risk of transurethral resection syndrome. If local facilities allow, fluid saline can be used instead of glycine for TURP
  • HoLEP:
    • suitable for prostates of all size
    • may be performed as a day case
    • low risk of bleeding, ED, and urinary incontinence
    • post-operative catheter duration is shorter compared with TURP
    • more tissue removed compared with TURP
  • Open prostatectomy:
    • used where HoLEP or other laser options are not available
    • traditionally used for prostates >100 cc
    • risk of infection, bleeding, deep-vein thrombosis
    • prolonged recovery time
    • good long-term outcomes
  • Photoselective vaporisation of the prostate (PVP):
    • may be performed as a day case
    • risk of erectile dysfunction, retrograde ejaculation, incontinence, and urethral stricture
    • post-operative catheter duration is shorter compared with TURP
    • the use of PVP is not currently supported by NICE in high-risk patients (i.e. men who have an increased risk of bleeding, prostates >100 cc, or urinary retention)
  • TURP:
    • procedure requires inpatient stay and indwelling catheter
    • risk of bleeding, infection, and urinary incontinence
    • established procedure with good long-term data and results

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This algorithm has been developed by MGP Ltd, the publisher of Guidelines, and the expert group was convened by MGP Ltd. Final editorial decisions rested with the Chair. NeoTract, Inc. had the opportunity to comment on the technical accuracy of this algorithm but the content is independent of and not influenced by NeoTract, Inc.

group members

Dr Jonathan Rees (Chair, GP with Special Interest in Urology), Jane Brocksom (Urology Nurse Specialist), Dr Jessica Garner (GP), Mark Rochester (Consultant Urological Surgeon)

further information

call MGP Ltd (01442 876100)

Date of preparation: September 2017