Advances in the Management of BPHMr C DawsonConsultant UrologistEdith Cavell HospitalPeterborough

Advances in the Management of BPHMr C DawsonConsultant UrologistFitzwilliam HospitalPeterborough

The Scale of the ProblemModerate to severe Lower Urinary Tract Symptoms (LUTS) occur in 25% of men over 50 years, and the incidence rises with ageApproximately 90% of men will develop histological evidence of BPH by 80 years of age

The Scale of the ProblemIncreasing because:Men are living longerProportion of Men over 50 years will increaseMen are better informed about health matters

Difficulties in Diagnosis and ManagementThe symptoms of BPH are the same as those of early Prostate CancerConfirmation of the presence of prostate cancer may be difficultThe need to treat (proven) cancer may not always be clear cut

Understanding Lower Urinary Tract Symptoms (after Abrams, Bristol, UK)

Storage SymptomsFrequencyNocturiaUrgencyUrge incontinenceBladder Pain

Voiding Symptoms Slow stream Intermittent flow Hesitancy Straining Terminal dribble

Physical SignsMay be fewLook for obvious uraemiaPalpate for full bladderExamine urethral meatus and palpate urethra for strictureDIGITAL RECTAL EXAMINATION (DRE) !!

Investigations for BPHUrea and electrolytes if clinically indicatedPSA (should we counsel patients?)Ultrasound urogramFlow rate (if you have access)IPSS

IPSS

A word about Prostate CancerNo symptoms specific for early prostate cancerPresenting symptoms are therefore those of BPHBiopsy of the prostate should be performed in those with abnormal DRE, or PSA above age-specific reference range

Prostate Specific AntigenSingle-chain glycoprotein of 240 aa residues and 4 carbohydrate side chainsPhysiological role in lysis of seminal coagulumProstate specific, but NOT cancer specific

Prostate Specific AntigenIn addition to prostate cancer, an elevated level may be found inIncreasing ageAcute urinary retention / Catheterisationafter TURP / Prostate BiopsyProstatitisBPH

A reduced level may be found in patients treated with Finasteride

The Problem with PSAMen with Prostate Cancer may have a normal PSAMen with BPH or other benign conditions may have a raised PSAMay 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 PSAPSA densityPSA VelocityAge-Specific PSA40-49 Years old

Prostate Specific AntigenPossiblySomeAttributes

The Management of BPHAdvances 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 TechniquesTransurethral Microwave Thermotherapy (TUMT)Transurethral Needle ablation (TUNA)Transrectal high-intensity focused ultrasound (HiFU)Transurethral electrovaporisation (TUVP)

Pharmacotherapy for BPHAlpha-blockers remain an important therapySelective -1a receptor blockers may have fewer side effects

Alpha blocker therapy

Pharmacotherapy for BPHFinasteride (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 therapiesHigh energy TUMT, and TUNA, have proven clinical efficacy between that of drug therapy and TUVP or laser therapyHiFU currently requires GA, is costly and time consuming, and appears unlikely to be popular at presentThe subjective response after MITs and TURP appear similar, but objective results superior for TURP

Surgical TherapiesTURP still the gold standard therapy, with which all other therapies must be consideredLaser therapy expensive to set upSignificantly reduced blood loss Catheter may be required post operativelyOpen Prostatectomy rarely required

ECH Urology Department Guidelines for the Management of BPHProduced after discussion between working party of General Practitioners and ConsultantsAgreed within the department of Urology

Protocol for the management of BPH

Protocol for the management of BPH

Future perspectives for the management of BPHMuch more emphasis on Quality of Life Minimally invasive therapies are improving and may yet challenge the superiority of TURP

Conclusions - BPHRemains an important cause of patient morbidityCorrect approach to assessment is importantMany 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 - BPHA large variety of MITs exist for BPH who fail drug therapy, but for most patients the gold standard surgical procedure remains TURPThe next few years will see many more techniques available to challenge the position of TURP

Thank you for your attention