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)
D e tr u s o r I n s t a b ility

B la d d e r H y p e r s e n s i t iv ity

Storage Symptoms
Frequency
Nocturia
Urgency
Urge incontinence
Bladder Pain

B la d d e r O u t le t O b s t r u c t i o n

D e tr u s o r F a ilu r e

Voiding Symptoms
Slow stream
Intermittent flow
Hesitancy
Straining
Terminal dribble

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

50-59 Years old
60-69 Years old
70-79 Years old

<2.5ng/ml
<3.5ng/ml
<4.5ng/ml
<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
G P A s s e s s e s P a tie n t
H is t o r y

IP S S S c o r e
DRE
U +E and PSA

F lo w r a t e a n d R e s id u a l v o lu m e if p o s s ib le
O p tio n s

R e fe r r a l t o U r o lo g y D e p a r t m e n t

M anagem ent by G P
( S e e n e x t s l id e )

N o rm a l D R E a n d P S A

A b n o rm a l D R E a n d P S A

E lig ib le fo r S h a r e d C a r e

O u t p a t ie n t a p p t w it h

P r o s t a t e C l in ic

C o n s u lta n t

Protocol for the management of

BPH
IP S S S c o re

M anagem ent

M ild
IP S S < 7
F lo w R a t e > 1 5 m ls / s
R e s id v o l < 1 0 0 m ls

W a tc h fu l W a itin g

M o d e ra te
IP S S 7 -2 0
F lo w r a t e < 1 5 m ls / s
R e s id v o l < 2 0 0 m ls

a lp h a -b lo c k e r s :
R e fe r if n o im p r o v e m e n t

S e ve re
IP S S > 2 0
F lo w r a t e < 1 0 m ls / s
R e s id v o l > 2 0 0 m ls

R e fe r to th e U r o lo g y
D e p a r tm e n t

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