Review and Update of Benign Prostatic Hyperplasia in General Practice

CLINICAL

Review and update of benign prostatic hyperplasia in general practice

Manasi Jiwrajka, William Yaxley, IT IS COMMON FOR MEN to present to a apnoea) as the cause of symptoms. The use Marlon Perera, Matt Roberts, general practitioner (GP) with symptoms of a frequency–volume chart or voiding Nigel Dunglison, John Yaxley, suggestive of bladder outflow obstruction, diary, and International Prostate Symptom Rachel Esler which is often due to benign prostatic Score (IPSS) tools, help to assess symptom enlargement (BPE). Benign prostatic severity and bother affecting quality of life hyperplasia (BPH) is the histological (QoL; Table 2).4 Background cause of BPE, which often results in lower The aim of physical examination Benign prostatic hyperplasia (BPH) is the most common benign tumour in urinary tract symptoms (LUTS) related is to exclude a palpable bladder as 1 men. Although men with BPH often to voiding, storage or post-micturition. well as phimosis, meatal stenosis or need medical or surgical management Not all LUTS in men are due to BPE, other pathology, including balanitis. from a urologist at some point and other causes of voiding dysfunction A digital rectal examination (DRE) is throughout the timeline of their disease, require exclusion (Table 1).2 Management recommended to evaluate the size of the most men are initially assessed and of LUTS due to BPE depends on symptom prostate and exclude a grossly malignant managed by a general practitioner (GP) severity or complicating factors and or hard prostate nodule suggestive of in the primary healthcare setting. includes observation (for men with prostate cancer, tenderness suggestive Objectives minimal symptoms), medical therapy, of prostatitis, and constipation.5 The aim of this article is to highlight minimally invasive surgical procedures, the principles of the pathogenesis, endoscopic prostatectomy and, presentation, assessment and Initial investigations occasionally, abdominopelvic surgery management of BPH in a primary care setting. for very large prostates. Initial investigations aim to exclude sinister causes of LUTS or complications Discussion Important history and of bladder outflow obstruction that Between 2009 and 2011, BPH was examination features require immediate treatment. Such managed by GPs at approximately investigations (Table 3) include urinalysis 228,000 general practice visits per International guidelines highlight the (to exclude haematuria, proteinuria and annum in Australia. Several changes in pharmaceutical agents and surgical importance of determining the severity of pyuria), serum creatinine and estimated intervention have occurred over the past LUTS and identifying complicating factors glomerular filtration rate (eGFR).6 Urine decade. As a result, it is imperative that such as urinary retention, macroscopic cytology should be considered in the GPs remain up to date with assessment haematuria, urinary tract infection (UTI) presence of haematuria, risk factors and management of BPH, are aware of or a personal or family history of prostate for urothelial carcinoma, or significant new therapies and understand when to cancer. Men may describe (i) voiding storage symptoms. In patients with refer to a urologist. (bladder emptying) symptoms such as moderate-to-severe symptoms or an weak stream, hesitancy and intermittency abnormal serum creatinine, a renal tract of flow or (ii) storage (bladder filling) ultrasound will show bladder capacity and symptoms such as urgency, daytime post-void urine residual volume, allow frequency and nocturia. A predominance for assessment for hydronephrosis and of storage symptoms would require provide an estimation of prostate volume.5 exclusion of other conditions such as Computerised tomography is not routinely primary bladder pathology/malignancy, recommended unless complicating features diabetes mellitus, ischaemic heart disease are suspected.5,6 and medications with diuretic properties.3 Some men are concerned that their In cases where the primary complaint urinary symptoms may be due to an is nocturia, efforts should first be made underlying prostate cancer. Prostate- to exclude nocturnal polyuria (then specific antigen (PSA) testing remains associated factors such as obstructive sleep controversial both in Australia and

internationally. The Royal Australian Medical therapy in men considering cataract surgery, College of General Practitioners (RACGP) given the increased risk of floppy iris recommends against PSA screening, Men with bothersome symptoms in syndrome.3,12 but acknowledges that the PSA debate the absence of complicating factors remains unclear and open to individual are appropriate candidates for a trial of 5-alpha reductase inhibitors interpretation.7 The Prostate Cancer medical therapy.6 Monotherapy is usually Foundation of Australia and Cancer initiated with an alpha-adrenoceptor 5-ARIs inhibit the conversion of Council Australia guidelines from 2016 antagonist. Combined therapy with a testosterone to dihydrotestosterone recommend PSA testing every two years 5-alpha reductase inhibitor (5-ARI) may (DHT) to reduce prostate growth and for men aged 50–69 years at average risk further improve symptoms in men with prostate volume.13 The most common of prostate cancer.8 This recommendation large prostate volumes. 5-ARIs prescribed on the Australian is supported by the Urological Society of Pharmaceutical Benefits Scheme (PBS) are Australia and New Zealand (USANZ). Alpha-adrenoceptor antagonists dutasteride and finasteride. Dutasteride inhibits type 1 and type 2 isoenzymes of Management Alpha-1 adrenoceptor blockade results in 5-alpha reductase, as opposed to type 2 smooth muscle relaxation in the prostate inhibition alone with finasteride.14 5-ARIs Treatment is mostly determined by and bladder neck.3 Uroselective agents, are most effective when prostate volume bother of symptoms, effect on QoL or such as alfuzosin, silodosin, tamsulosin is >40 mL.5 whether any complicating features are and terazosin, have been shown to The most common side effects of identified. A conservative approach, produce comparable improvement in 5-ARIs are erectile dysfunction, decreased with reassurance and behavioural symptom score and maximal urinary flow libido, decreased ejaculate and decreased modification, can be considered in men rate with fewer systemic side effects.3,11 sperm count.15 In contrast to the rapid with mild, non-bothersome LUTS and Prazosin is cheaper than other agents and onset of action of alpha-adrenoceptor normal baseline investigations, as their is commonly used but has a less favourable antagonists, 5-ARIs can take several risk of progression is low.9,10 Behavioural side-effect profile and requires multiple months before maximum improvement modifications include reducing diuretics daily dosing; thus, it is not recommended in symptoms is obtained.1 Men should be (caffeine, alcohol), bladder irritants by international BPH guidelines.3 warned that 5-ARI therapy can decrease (acidic, spicy foods), evening fluid intake Men should be warned of the PSA levels by approximately 50% after and constipation.9,10 Bladder training and side effects of alpha-adrenoceptor 6–12 months of treatment.16,17 As a result, pelvic floor exercises may improve bladder antagonists, including retrograde in men on a 5-ARI, an increase in PSA capacity and reduce storage symptoms. ejaculation (higher with uroselective above the nadir should prompt closer A yearly GP review of symptoms, with agents), erectile dysfunction, nasal evaluation of PSA levels to exclude an urinalysis and creatinine/eGFR, is congestion, hypotension, dizziness and upward trend suggestive of prostate suggested to monitor for progression.2 tachycardia.1 Caution is also required cancer, rather than waiting for the PSA to be elevated outside the reference range before considering urological evaluation. Table 1. Differential diagnoses for lower urinary tract symptoms Combination therapy Benign and neoplastic Neurological Other causes of lower conditions of the lower conditions urinary tract symptoms Since 2016, tamsulosin plus dutasteride urinary tract has been available to GPs to prescribe as a • Urinary tract infection • Parkinson’s disease • Polyuria from renal or combined formulation without specialist • Prostatitis • Stroke/cerebrovascular cardiac dysfunction approval.18 This fixed-dose combination • Bladder calculi accident • Nocturnal polyuria and is subsidised by the PBS and therefore sleep apnoea • Interstitial cystitis • Multiple sclerosis available at a lower cost than both agents • Iatrogenic from 2 • Urethral stricture • Cerebral atrophy separately. medications • Phimosis • Head injury Two randomised controlled trials of more than 3000 men compared • Overactive bladder • Spinal cord injury/ syndrome surgery or degenerative combination therapy with monotherapy. disc disease • Prostate cancer Overall, combination therapy was • Prior pelvic surgery superior to either alpha-adrenoceptor • Urothelial carcinoma of the bladder including antagonist or 5-ARI therapy alone carcinoma in situ in improving LUTS and reducing 12 • Urethral cancer progression. For men with a prostate volume of >40 mL and a PSA of >1.5,

472 | REPRINTED FROM AJGP VOL. 47, NO. 7, JULY 2018 © The Royal Australian College of General Practitioners 2018 REVIEW AND UPDATE OF BENIGN PROSTATIC HYPERPLASIA CLINICAL

Table 2. The International Prostate Symptom Score4

Urinary symptoms over the past month Less than one Less than About half More than Almost Not at all (symptom score criteria) time in five half the time the time half the time always

1. Incomplete emptying How often have you had a sensation of not 0 1 2 3 4 5 emptying your bladder completely after you finished urinating?

2. Frequency How often have you had to urinate less 0 1 2 3 4 5 than two hours after you finished urinating?

3. Intermittency How often have you found you stopped 0 1 2 3 4 5 and started again several times when you urinated?

4. Urgency How often have you found it difficult to 0 1 2 3 4 5 postpone urination?

5. Weak stream How often have you had a weak urinary 0 1 2 3 4 5 stream?

6. Straining How often have you had to push or strain 0 1 2 3 4 5 to begin urination?

Five or more None One time Two times Three times Four times times

7. Nocturia How many times did you most typically get up to urinate from the time you went 0 1 2 3 4 5 to bed at night until the time you got up in the morning?

Quality of life due to urinary problems

Mixed – about Mostly Mostly Delighted Pleased equally satisfied Unhappy Terrible Satisfied dissatisfied and unsatisfied

If you were to spend the rest of your life with your urinary 0 1 2 3 4 5 6 condition just the way it is now, how would you feel about that?

The final score is the sum of questions 1–7

combination therapy resulted in Phosphodiesterase 5 inhibitors treatment option, several randomised greater reductions in the risk of urinary controlled trials have shown that PDE5 retention or the need for surgery than BPE and erectile dysfunction can occur inhibitors improve IPSS, symptoms monotherapy.19 However, urological concomitantly, and phosphodiesterase 5 and QoL, compared with placebo.3 opinion varies regarding balancing (PDE5) inhibitors (eg sildenafil) have Furthermore, the combination of an the benefit of combination therapy been associated with some improvement alpha-adrenoceptor antagonist and PDE5 over monotherapy against the risk of in voiding symptoms.3 Though not inhibitor is superior to PDE5 inhibitor increased sexual dysfunction.12,20 traditionally recognised as a first-line monotherapy.21

Table 3. Initial investigations in the general practice setting

Investigation Reason for investigation Comments

Urinalysis Exclude leucocytosis, haematuria, proteinuria, Follow up with urine culture if abnormality on urinalysis pyuria and glycosuria

Serum creatinine/ Exclude renal injury from primary renal Follow up with imaging if abnormal eGFR. Can be useful estimated glomerular dysfunction or high-pressure bladder outflow as a follow-up test if renal impairment is suspected filtration rate (eGFR) obstruction

Urinary tract ultrasound Assessment of prostate volume, bladder Bladder scanners are available for general practitioner wall and residual urine; used to exclude use to calculate residual volume, but a formal ultrasound hydronephrosis requires a radiology unit

Prostate-specific Exclude prostate cancer Controversial; most guidelines recommend the use of antigen (PSA) serum PSA if prostate cancer diagnosis will influence management or if the test will assist in decision making

the morbidity of traditional approaches, Authors Triggers for urological referral Manasi Jiwrajka BA, MBBS, MPhil candidate, especially retrograde ejaculation and Resident Medical Officer, Urology Department, Royal There are numerous clinical indications bleeding; however, longitudinal outcome Brisbane and Women’s Hospital, Brisbane, Qld; 25 Faculty of Medicine, The University of Queensland, for urological referral including urinary data are limited. The prostatic urethral Brisbane, Qld; Queensland Institute of Medical retention, evidence of hydronephrosis lift procedure, which deploys adjustable Research, Brisbane, Qld. [email protected] on ultrasound, symptoms refractory to implants to retract obstructing lateral William Yaxley MBBS, Resident Medical Officer, Associate Lecturer, Urology Department, Royal medical management, recurrent UTIs, prostatic lobes, was approved by the Brisbane and Women’s Hospital, Brisbane, Qld; gross haematuria, bladder stones, renal Therapeutic Goods Administration in Faculty of Medicine, The University of Queensland, Brisbane, Qld insufficiency or large bladder diverticula.1,2 August 2012 and has become a commonly Marlon Perera MBBS, Urology Registrar, PhD performed day procedure.26,27 Patients candidate, Urology Department, Royal Brisbane are often catheter-free on discharge, and Women’s Hospital, Brisbane, Qld; Faculty of Surgical management Medicine, The University of Queensland, Brisbane, and there have been no reported de Qld; Department of Surgery, Austin Health, University Endoscopic prostatectomy novo cases of sexual dysfunction.28 The of Melbourne, Vic Matt Roberts MBBS, PhD, Urology Registrar and Transurethral resection of the prostate prostatic urethral lift is usually unsuitable Lecturer, Urology Department, Royal Brisbane and (TURP) is the gold standard surgical for men with urinary retention, Women’s Hospital, Brisbane, Qld; Faculty of Medicine, treatment for symptomatic BPH. obstructing median lobes or prostates The University of Queensland, Brisbane, Qld Nigel Dunglison MBBS, Consultant Urologist, 29 Risks are well established and include >80 mL. Urology Department, Royal Brisbane and Women’s retrograde ejaculation, impotence, Hospital, Brisbane, Qld incontinence, urethral stricture, bladder John Yaxley MBBS, Consultant Urologist, Associate Conclusions Professor, Urology Department, Royal Brisbane and neck contracture, bleeding or perforation Women’s Hospital, Brisbane, Qld; Faculty of Medicine, of prostate capsule resulting in ‘TURP LUTS are a common reason for men to The University of Queensland, Brisbane, Qld Rachel Esler MBBS, Consultant Urologist, Director 1 syndrome’. Laser vaporisation and present for GP review. Uncomplicated of Unit, Urology Department, Royal Brisbane and enucleation treatments are also used LUTS and minimal bother warrant an Women’s Hospital, Brisbane, Qld because of shorter hospitalisation initial conservative approach. Men Competing interests: None. Provenance and peer review: Not commissioned, duration, shorter catheter time, lower with more bothersome symptoms can externally peer reviewed. transfusion rates and less clot retention, be initially managed with an alpha- compared with a TURP; however, no adrenoceptor antagonist, while an References difference in symptom improvement or additional 5-ARI can be considered 1. McAninch JW, Lue TF. Smith and Tanagho’s QoL has been shown.22–24 for men with larger prostates. Surgery general urology. New York: McGraw-Hill, 2013. 2. Woo HH, Gillman MP, Gardiner R, Marshall is recommended for men who are V, Lynch WJ. A practical approach to the Minimally invasive surgical therapy bothered by symptoms and fail to management of lower urinary tract symptoms Transurethral incision of the prostate respond to medical management or have among men. Med J Aust 2011;195(1):34–39. 3. Lawrentschuk N, Perera M. Endotext: Benign involves an incision of the bladder neck complications such as hydronephrosis, prostate disorders. South Dartmouth, USA: without removal of prostatic tissue. It is recurrent UTIs, progressive deterioration MDText.com Inc, updated 14 March 2016. used for men with small prostates and has of residual volume, macroscopic 4. McConnell JD, Barry MJ, Bruskewitz RC. Benign prostatic hyperplasia: Diagnosis and treatment. 1 outcomes comparable with TURP. More haematuria or very poor maximum Agency for Health Care Policy and Research. Clin recently, aquablation has served to reduce velocity on uroflow studies. Pract Guidel Quick Ref Guide Clin 1994;(8):1–17.

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