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 Bladder Outlet Obstruction Detrusor Failure

Storage Symptoms Voiding Symptoms

Frequency Slow stream
Nocturia Intermittent flow

Urgency Hesitancy
Straining
Urge incontinence
Terminal dribble
Bladder Pain
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

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 <2.5ng/ml
50-59 Years old <3.5ng/ml
60-69 Years old <4.5ng/ml
70-79 Years old <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

-blocker therapy (including selective blockers of -

1a receptors)
5- -reductase inhibitors - Finasteride (Proscar)
Minimally invasive Techniques
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
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 Watchful Waiting

IPSS<7
Flow Rate >15 mls/s
Resid vol < 100 mls

Moderate alpha-blockers:
IPSS 7-20 Refer if no improvement
Flow rate < 15mls/s
Resid vol <200 mls

Severe Refer to the Urology

IPSS > 20 Department
Flow rate < 10 mls/s
Resid vol > 200 mls
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
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
Thank you for your attention