Prostate Disease

Benign Prostatic Hyperplasia (BPH) Investigations • Urinalysis or midstream urine. The GP’s role • If suspect urinary retention/large post void residual volume. - Ultrasound (Kidneys and bladder). • GPs are typically the first point of contact for men with BPH. - Renal function (Creatinine). • The GP’s role in the management of BPH includes clinical assessment, treatment, referral and follow-up. • PSA: - If suspect prostate cancer (e.g. based on prostate Overview examination) - As part of screening of prostate cancer, after discussion of 1 • BPH is the non-cancerous enlargement of the prostate gland . pros and cons • Whilst not normally life threatening, BPH can impact - Routine PSA screening is not necessary for patients with 2 considerably on quality of life . BPH. Patients with LUTS are not at increased risk of having prostate cancer. Diagnosis PSA levels for different age groups of Western men4 Medical history Age range Serum PSA Serum PSA (ng/mL) • Lower urinary tract symptoms (LUTS). years (ng/mL) median upper limit of normal

Urinary symptoms of BPH 40-49 0.7 2.5 Obstructive symptoms: 50-59 1.0 3.5 • Hesitancy 60-69 1.4 4.5 • Weak stream • Post micturition dribble 70-79 2.0 6.5 • Sensation of incomplete bladder emptying. Other PSA tests Overactive symptoms: • PSA velocity or doubling time: if the PSA level doubles in 12-months it may indicate prostate cancer or prostatitis. • Frequency An elevated PSA and a stable velocity suggest BPH. • Urgency (if severe incontinence) -Free-to-total PSA ratio: high ratio (> 25%) suggests BPH; • Nocturia. low ratio (< 10%) suggests prostate cancer. Other: -Prostate Health Index (PHI): not covered by the MBS, PHI • Nocturnal incontinence thought to be more specific for diagnosing prostate cancer than PSA level alone; good quality evidence lacking & • Urinary retention. not recommended in Australian prostate cancer testing. Some men with BPH may not present with many or any symptoms guidelines. of the disease. • Creatinine levels. Symptom score • Post-void residual urine (ultrasound). • Evaluation of symptoms contributes to treatment allocation Investigations by the urologist and response monitoring. • As per GP investigations as indicated +/-. 3 • The International Prostate Symptom Score (IPSS) • Uroflowmetry and post void residual assessment. questionnaire is recommended. • Voiding diary. Physical examination • Cystoscopy. • Digital rectal examination (DRE) can estimate prostate size • Urodynamic assessment. and identify other prostate pathologies. • Basic neurological examination. • Perianal sensation and sphincter tone. • Bladder palpation. • Calibre of the urethral meatus. • Phimosis. Management Surgery Indications for surgery are similar to the indications for referral Observation and review: for mild or low impact symptoms to a urologist. Surgery can be considered when medications are • Optimise through reassurance, education, periodic monitoring no longer suitable for whatever reason. Cessation of medication and lifestyle modifications. therapy usually results in recurrence of symptoms. • Consider adjustment of medication (e.g. timing of diuretic). There are multiple operations available. The gold standard operation is a transurethral resection of the prostate (TURP). Medical therapy: for moderate to severe symptoms There are however numerous operations that are available. Alpha blockers (once daily) Each has their pros and cons. When considering the operation • These are generally 1st line. the patient is undertake there are different factors that are considered such as: - Amsulosin. - Silodosin. • Prostate size/configuration - Alfuzosin. • Anti-coagulation status • Side effects (e.g. preference to preserve antegrade ejaculation) • Side effect profiles may favour tamsulosin. • Day stay vs overnight stay 5α-reductase-inhibitors (5ARIs) • Catheter duration • Dutasteride. • Co-morbidities (long term SPC) • Finasteride. • Durability of operation. Very rarely used as monotherapy. The operations available include:

Combination therapy • Transurethral Resection of the Prostate (TURP) • Dutasteride and tamsulosin. • Transurethral Incision of the Prostate (TUIP) • Better for patients with large prostates (> 30 ml). • Green light laser resection of the prostate • 5ARI can affect sexual function so consider carefully in sexually • Minimally invasive insertion of small retractors into prostate active men. • Plasma Vaporisation • Controversy regarding 5ARI association with prostate cancer • Water Vapour therapy risk so recommend PSA surveillance. If PSA increased whilst • Holmium Laser Enucleation of the Prostate (HoLEP). on 5ARI, refer to urologist to exclude prostate cancer. Long term catherisation: Other drugs • Last resort for patients unfit/unwilling for surgery but with Bladder directed medications are most commonly used for complications (e.g. urinary retention) overactive bladder symptoms. • Supra-pubic catheter is preferred to indwelling urethral • Beta-3 adrenergic agonist – Mirabegron. catheter - Requires blood pressure monitoring within first week. • Intermittent Self catheterisation should also be considered • Anticholinergics. in such patients. - Oxybutynin. Follow-up - Solifenacin. • It is appropriate for the GP to monitor and follow-up a patient - Darifenacin. with respect to all the treatment modalities. However, if the • Side effects include dry mouth, dry eyes and/or constipation. patient is not responding to medical treatment, refer to the urologist. Urologist referral • Men who have had TURP remain at risk for prostate cancer and need routine prostate cancer checks, as per guidelines. Treatment • Urinary retention history. Recommended follow-up timeline after BPH treatment • Urinary tract infection. Treatment First year after Annually • Haematuria. modality treatment thereafter • Failed medical therapy. 6 12 6 • Incontinence (of any type). weeks weeks months • Post void residual of > 100 ml. Observation and review X X • Severe symptoms (especially if poorly responsive 5α-reductase inhibitors X to medications). • Renal impairment. α-blockers X • Bladder stones. Surgery or minimal invasive treatment • Cancer suspected — prostate or bladder. • Associated Neurological condition (e.g. Parkinson’s disease, Multiple sclerosis). Prostatitis Chronic nonbacterial prostatitis (chronic prostate pain syndrome); treatment is difficult and cure is often not possible. The GP’s role Treatment focus is on symptom management, to improve quality of life. Non-medical therapy is recommended as the initial • GPs are typically the first point of contact for men with treatment. prostatitis. Medication options5 • The GP’s role in the management of prostatitis includes clinical • α-blockers. assessment, treatment, referral and follow-up. - Suited to patients with moderate/severe LUTS. Overview - Tamsulosin. - Silodosin. • Prostatitis is inflammation of the prostate gland. - Alfuzosin. • It can be a result of bacterial or non-bacterial infection. - Side effect profiles may favour tamsulosin. • Acute bacterial prostatitis, the least common form, can be • Antibiotics (not all antibiotics penetrate the prostate gland). serioius if the infection is left untreated. - Recommend: Norfloxacin, Ciprofloxacin, Trimethoprim, • Whilst not normally life threatening, prostatitis can impact Sulphamethoxazole/Trimethoprim, Erythromycin, Gentamicin. considerably on a man’s quality of life. - Young men with confirmed Chlamydia prostatitis: Doxycycline. Diagnosis • Analgesics.

Medical history • Non-steroidal anti-inflammatory drugs. • Urinary symptoms. Surgical options • Pain. • Transurethral incision of the bladder neck.

Symptoms of prostatitis • Transurethral resection of the prostate. • Dysuria — painful urination. Surgery has a very limited role and requires an additional, specific indication (e.g. prostate obstruction, prostate calcification). • Urgent need to urinate. • Frequent urination. Other options • Painful ejaculation. • Lifestyle changes: avoid activity that involves vibration or • Lower back pain. trauma to the perineum (e.g. bike riding, tractor driving, long- • Perineal pain. distance driving, cut out caffeine, spicy foods, alcohol, avoid constipation). • Chills and/or fever. • Some patients may benefit from treatment by a specialised • Muscular pain. pelvic floor physiotherapist, which may include pelvic floor • General lack of energy. relaxation techniques and trigger point massage. Investigations • Prostate massage. • Digital rectal examination (DRE): • Supportive therapy: biofeedback, relaxation exercises, acupuncture, massage therapy, chiropractic therapy - Should not be performed if you suspect acute severe and meditation. prostatitis because it can be very painful • Heat therapy. - Some tenderness and swelling may accompany sub-acute prostatitis. Referral • Prostate specific antigen (PSA) levels: Indicators for referral to a urologist - Levels may be dramatically high • When the GP is not confident in managing the condition. - PSA velocity: if the PSA level doubles in 12-months it may indicate prostate cancer or prostatitis. • If the GP is concerned there are other potential diagnoses, particularly prostate or bladder cancer. • Urine analysis: • Those who do not respond to initial first-line therapy such as - First pass urine: Chlamydia urine PCR test antibiotics and/or α-blockers. For these patients, more invasive - Midstream urine: MC&S investigations, such as cystoscopy and transrectal prostate - Urine PCR for STIs should be done if Chlamydia or other ultrasound scan, are commonly done. STI a likely cause. Follow-up • The need for urologist follow-up depends on the patient’s Management progress. • Most urologists will refer back to the GP to monitor the Treatment progress of the patient. • There are several therapeutic options available. Evidence for • The urologist will seek re-referral if the patient’s progress is not benefits of these treatment options is limited; however, they satisfactory. may be trialled with the patient. • A GP can re-refer if they do not feel comfortable in managing • Urologists’ use of the following forms of treatment will vary a relapse. according to the individual, their condition and the stage of their treatment. • Most patients will have antibiotic therapy at some stage. Bacterial prostatitis (acute and chronic) can be treated using antibiotics. Once diagnosed, rapid treatment is essential to avoid further complications. References

1. Ng & Baradhi. Benign Prostatic Hyperplasia. In: StatPearls. Available at www.ncbi.nlm.nih.gov/books/NBK558920/ 2. Hong, et al., 2005. The importance of patient perception in the clinical assessment of benign prostatic hyperplasia and its management. BJU International 3. Barry et al., 2017. The American Urological Association Symptom Index for Benign Prostatic Hyperplasia. The Journal of Urology 4. Oesterling, 1993. Serum Prostate-Specific Antigen in a Community-Based Population of Healthy Men. JAMA 5. Davis & Silberman. Bacterial Acute Prostatitis. In: StatPearls. Available at www.ncbi.nlm.nih.gov/books/NBK459257/

Date reviewed: March 2021 Clinical review by Mr Adam Landau, Australian Urology Associates and Mr Darren Katz, Men’s Health Melbourne © Healthy Male (Andrology Australia) 2007

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