• Benign prostate hypertrophy (BPH)

    Source – Israeli Urologists Association

    https://www.ima.org.il/userfiles/image/Ne61_hatalatSheten.pdf

    Summary

    Benign prostate hypertrophy (BPH) is a common and progressive phenomenon in older men. The urination disturbance may occur during the urine storage and emptying stages or after the completion of the urination; it might effect to the quality of life and be caused by several factors. The goal of the treatment is to improve the symptoms and quality of life of the patient, in addition to preventing worsening symptoms and complications resulting from benign prostatic enlargement. Drug therapy is the basis for treatment, while surgical or minimally invasive treatment is intended for patients who are not interested in drugs or those whose symptoms have not been significantly alleviated despite drug treatment and are interested in invasive treatment.

     

    Introduction

    Benign prostatic hypertrophy (BPH) is a common and progressive phenomenon in men older than 40 years. Lower urinary tract symptoms (LUTS) can occur in the storage and emptying stages or after urination. The disturbances in the storage phase are expressed mainly in frequency of urination, urgency (difficulty in postponing urination), urinary incontinence, and urination at night. Disorders in the emptying phase are mainly manifested in a slow, interrupted flow of urine, the need to exert abdominal pressure to remove the urine, initial hesitation and an incomplete feeling of emptying. Final urine dripping is characteristic of the post-urination phase. LUTS impair quality of life and are a common cause of urologic treatment in men. The LUTS origin is multifactorial and can be caused by BOO (Bladder Outlet Obstruction), over-stimulation of the Detrusor (bladder muscle) due to benign enlargement of the prostate, DO (Detrusor Overactivity), Detrusor underactivity and night time urination due to increased nighttime urine production (Nocturia/Nocturnal polyuria). LUTS are related to the activity of muscarinic and adrenergic receptors in the urinary tract. The development and growth of the prostate is affected by testosterone and dihydrotestosterone.

     

    Prospective risk factors for LUTS progression against an enlarged prostate are age, prostate size over 40-30 milliliters, prostate specific antigen (PSA) is equal to or greater than 1.5 nanograms per milliliter, and LUTS severity according to the IPSS questionnaire. BOO may cause hydronephrosis and impaired kidney function.

     

     

    Diagnosis

     

    Medical history: Should focus on lower urinary tract symptoms, general medical conditions including surgeries, drug therapy, sexual functioning, and family-related history.

     

    A symptom score is used to assess the severity of the symptoms. It is a prognostic measure of disease progression and serves as a tool for monitoring treatment. The commonly used questionnaire is IPSS on its eight questions.

     

    Physical Examination

    Physical examination should focus on rectal examination to assess prostate size, tissue, and neurologic evaluation.

     

    Blood and urine tests

    PSA: A recommended test for men with BPH in those cases where the test result changes the patient's therapeutic approach and to assess the risk of disease progression.

    Creatinine: Kidney function test

    Urinalysis, Urine for culture

    Urinary tract ultrasound including upper urinary tract, bladder, urine residue and prostate size assessment.

    Uroflowmetry test: Optional

    Cystoscopy: Not recommended in the initial assessment

    Urodynamics: Not recommended in the initial assessment

     

     

    Treatment

    OBJECTIVE: To improve LUTS and quality of life, to prevent worsening of the symptoms and complications of BPH.

     

    Treatments

    Lifestyle modification and follow-up - Behavioral treatment - life style modification

    This approach without further treatment is suitable for patients reporting mild symptoms (IPSS less than 7) or whose quality of life has not been significantly affected.

     

    Lifestyle change can help improve quality of life by adjusting drinking habits, reducing caffeine intake, modifying medications if possible, avoiding prolonged holding, and treating constipation.

    These recommendations may be given to the appropriate patient or as a supplement to the patient being treated with medication.

     

    Medication

    This treatment approach is suitable for patients with significant LUTS or for patients with impaired quality of life due to LUTS.

     

    Α-1 adrenergic receptor blockers (alpha 1 adrenergic receptor antagonists)

    Medicines from this group improve symptoms (decreased IPSS score) and urinary flow. Their clinical efficacy is demonstrated after a few days. Medications from this group can be used as a first line for treating men with moderate to severe urinary disorders.

     

    Drugs in this group have similar efficacy at the appropriate dosage. They differ in frequency and nature of side effects. These drugs do not affect the natural course of the disease and the growth rate of the prostate. Long-term Alpha-blockers do not reduce urinary retention rates. It is recommended to use medications that do not require titration. In addition to the known side effects, a side effect of Intraoperative Floppy Iris Syndrome (IFIS) was reported in the use of alpha receptor blockers during cataract surgery.

     

    In patients with acute urinary retention, supplementation with α-1 adrenergic receptor blockers prior to weaning off the catheter improves the likelihood of successful rehab.

     

    reductase inhibitors

    This drug group improves symptoms (decrease in IPSS), urinary flow, decrease prostate size, alter the natural progression of the disease, thus reducing the chances of urinary retention and need for surgery. Their clinical efficacy is demonstrated after 12-6 months of use.

     

    5α-reductase inhibitors (ARI-5) are the first line treatment for men with mild to severe urination disorders with prostate larger than 30 milliliters or PSA levels above 1.5 nanograms per milliliter. After 12-6 months of treatment, PSA values ​​are expected to decline to about half of the value before treatment begins.

     

    The administration of these drugs may reduce the incidence of macroscopic hematuria from the prostate.

     

    Antimuscarinic

    Antimuscarin therapy is an option in men with prostate enlargement who suffer mainly from hoarding symptoms. Medicines from this group improve symptoms. Their clinical efficacy is demonstrated after several weeks. All of these drugs have similar efficacy in the appropriate dosage. They differ in frequency and nature of side effects. It is recommended not to start antimuscarins in patients with residual urine greater than 250 cc.

     

    Phosphodiesterase inhibitors 5 (PDE5)

    Daily treatment with phosphodiesterase 5 inhibitors is an option in men with prostate enlargement who suffer from urinary disorders. This group of drugs improves symptoms, and their clinical efficacy is demonstrated after several weeks.

     

    These drugs are prohibited for use in patients taking nitrates, in patients with Unstable Angina, a recent heart attack (3 months), recent stroke (6 months), congestive heart failure, kidney failure, or severe liver failure in patients with non-arteritic anterior ischemic optic neuropathy (NAION) and in patients taking doxazosin or terazosin α blockers.

     

    Desmopressin

    In patients with prostatic hyperplasia who suffer from urinary tract disorders and especially nocturnal polyuria, desmopressin may be considered. Desmopressin reduces the volume of urine production at night. Take the medicine before bedtime and avoid drinking an hour before taking it and 8 hours later. The drug can cause hyponatremia, which increases with age and, accordingly, requires sodium monitoring in the blood.

     

    Combined drug therapy

    A combination of α-1 adrenergic receptor blockers and AR-5 blockers

    The first-line combination is suitable for treating men with mild to severe urination disorders with prostate larger than 30 milliliters or PSA levels above 1.5 nanograms per milliliter. Drug combination has been shown to be more effective in preventing disease progression, urinary retention, and the need for prostate surgery than any drug.

     

    Herbal therapy

    Herbal treatment and supplements are not recommended as a standard treatment for BPH. It can be prescribed to a patient who is interested in such treatment and there has no contra-indication.

     

    Intrusive treatments

    Surgery

    Surgery is an immediate solution to bladder obstruction and disorders caused by BPH.

     

    The choice of surgical method depends on the size of the prostate, the experience and preference of the surgeon, the risk factors for surgery, and the patient's preference.

     

    Absolute indications for surgery: Urinary retention after unsuccessful withdrawal from catheter, urinary retention in the presence of an selling of the kidney collecting ducts and kidney failure.

     

    Relative indications for surgery: failure of drug therapy, urinary infections as a complication of BPH, recurrent urinary bleeding due to BPH that did not respond to drug therapy, and stones in the bladder.

     

    The patient may choose the surgical treatment as the first treatment option, after he has been presented with all the treatment options and the advantages and disadvantages of the various treatments have been presented to him.

     

    Changes in prostate size during urological follow-up, large urine residues, increased PSA values, slow urinary flow, and adult age are risk factors for BPH progression, but they are not an absolute indication of surgery.

     

    Types of surgery

    TURP (Trans Urethral Resection of the Prostate): Standard prostate surgery is less than 80 cc

    TUIP (Trans Urethral Incision of the Prostate): Preserved as a treatment for a prostate less than 30 cc, provided that there is no enlarged middle lobe, this has a reduced chance of developing a complication of ejaculation and an increased likelihood of future surgical intervention.

    SPP / RPP (Prostatectomy / Retro Pubic Prostatectomy): Open-access surgery is recommended as a large prostate surgery or surgery that requires opening the bladder (such as removing a bladder section or removing a large stone from the bladder)

    TUVP (Electrical, Trans Urethral Vaporization of the Prostate): A therapeutic alternative to TURP / TUIP

    Laser Prostatectomy (HoLP = Holmium Laser Resection of the Prostate, HoLEP = Holmium Laser Enucleation of the Prostate) can be used as a therapeutic alternative to TURP or SPP / RPP.

     

    Minimally invasive treatments

    TUMT (Trans Urethral Microwave Thermotherapy), TUNA (Transurethral needle ablation), VLAP (Visual laser ablation of the prostate), ILC (Intersitial Laser Coagulation) are all types of minimally invasive treatments, some of which can be performed in an ambulatory manner.

     

    Those that can be performed under local anesthesia are suitable for patients with high surgical risk.

     

    None of the methods demonstrated an advantage in improving long-term symptoms compared with standard surgical treatment.

     

    Follow-up after treatment

    The monitoring tools will be determined based on the type of treatment the patient receives, the severity of his symptoms, his character and his response to the treatment.

     

    Change lifestyle only

    Re-evaluation after 6 months to check whether the patient condition is stable and did not change for the worse.

     

    Treatment of alpha blockers with and without combination with other drugs

    Re-evaluation after 4-6 weeks of treatment. If the treatment helps and there are no side effects that warrant a change in treatment - it is recommended to follow up after 6 months. If the situation is stable continue an annual follow up.

     

     

    Summary

    Urinary symptoms in men with benign prostatic hyperplasia are common in men over the age of 40. It affects the quality of life of patients. The goal is to identify the cause of the disorders, changing lifestyle habits, prescribing proper medications, as well as invasive medical treatment such as surgery to improve the quality of life of the patients and prevent the progression of the symptoms.

  • Benign prostate hypertrophy (BPH)

    Source – Israeli Urologists Association

    https://www.ima.org.il/userfiles/image/Ne61_hatalatSheten.pdf

    Summary

    Benign prostate hypertrophy (BPH) is a common and progressive phenomenon in older men. The urination disturbance may occur during the urine storage and emptying stages or after the completion of the urination; it might effect to the quality of life and be caused by several factors. The goal of the treatment is to improve the symptoms and quality of life of the patient, in addition to preventing worsening symptoms and complications resulting from benign prostatic enlargement. Drug therapy is the basis for treatment, while surgical or minimally invasive treatment is intended for patients who are not interested in drugs or those whose symptoms have not been significantly alleviated despite drug treatment and are interested in invasive treatment.

     

    Introduction

    Benign prostatic hypertrophy (BPH) is a common and progressive phenomenon in men older than 40 years. Lower urinary tract symptoms (LUTS) can occur in the storage and emptying stages or after urination. The disturbances in the storage phase are expressed mainly in frequency of urination, urgency (difficulty in postponing urination), urinary incontinence, and urination at night. Disorders in the emptying phase are mainly manifested in a slow, interrupted flow of urine, the need to exert abdominal pressure to remove the urine, initial hesitation and an incomplete feeling of emptying. Final urine dripping is characteristic of the post-urination phase. LUTS impair quality of life and are a common cause of urologic treatment in men. The LUTS origin is multifactorial and can be caused by BOO (Bladder Outlet Obstruction), over-stimulation of the Detrusor (bladder muscle) due to benign enlargement of the prostate, DO (Detrusor Overactivity), Detrusor underactivity and night time urination due to increased nighttime urine production (Nocturia/Nocturnal polyuria). LUTS are related to the activity of muscarinic and adrenergic receptors in the urinary tract. The development and growth of the prostate is affected by testosterone and dihydrotestosterone.

     

    Prospective risk factors for LUTS progression against an enlarged prostate are age, prostate size over 40-30 milliliters, prostate specific antigen (PSA) is equal to or greater than 1.5 nanograms per milliliter, and LUTS severity according to the IPSS questionnaire. BOO may cause hydronephrosis and impaired kidney function.

     

     

    Diagnosis

     

    Medical history: Should focus on lower urinary tract symptoms, general medical conditions including surgeries, drug therapy, sexual functioning, and family-related history.

     

    A symptom score is used to assess the severity of the symptoms. It is a prognostic measure of disease progression and serves as a tool for monitoring treatment. The commonly used questionnaire is IPSS on its eight questions.

     

    Physical Examination

    Physical examination should focus on rectal examination to assess prostate size, tissue, and neurologic evaluation.

     

    Blood and urine tests

    PSA: A recommended test for men with BPH in those cases where the test result changes the patient's therapeutic approach and to assess the risk of disease progression.

    Creatinine: Kidney function test

    Urinalysis, Urine for culture

    Urinary tract ultrasound including upper urinary tract, bladder, urine residue and prostate size assessment.

    Uroflowmetry test: Optional

    Cystoscopy: Not recommended in the initial assessment

    Urodynamics: Not recommended in the initial assessment

     

     

    Treatment

    OBJECTIVE: To improve LUTS and quality of life, to prevent worsening of the symptoms and complications of BPH.

     

    Treatments

    Lifestyle modification and follow-up - Behavioral treatment - life style modification

    This approach without further treatment is suitable for patients reporting mild symptoms (IPSS less than 7) or whose quality of life has not been significantly affected.

     

    Lifestyle change can help improve quality of life by adjusting drinking habits, reducing caffeine intake, modifying medications if possible, avoiding prolonged holding, and treating constipation.

    These recommendations may be given to the appropriate patient or as a supplement to the patient being treated with medication.

     

    Medication

    This treatment approach is suitable for patients with significant LUTS or for patients with impaired quality of life due to LUTS.

     

    Α-1 adrenergic receptor blockers (alpha 1 adrenergic receptor antagonists)

    Medicines from this group improve symptoms (decreased IPSS score) and urinary flow. Their clinical efficacy is demonstrated after a few days. Medications from this group can be used as a first line for treating men with moderate to severe urinary disorders.

     

    Drugs in this group have similar efficacy at the appropriate dosage. They differ in frequency and nature of side effects. These drugs do not affect the natural course of the disease and the growth rate of the prostate. Long-term Alpha-blockers do not reduce urinary retention rates. It is recommended to use medications that do not require titration. In addition to the known side effects, a side effect of Intraoperative Floppy Iris Syndrome (IFIS) was reported in the use of alpha receptor blockers during cataract surgery.

     

    In patients with acute urinary retention, supplementation with α-1 adrenergic receptor blockers prior to weaning off the catheter improves the likelihood of successful rehab.

     

    reductase inhibitors

    This drug group improves symptoms (decrease in IPSS), urinary flow, decrease prostate size, alter the natural progression of the disease, thus reducing the chances of urinary retention and need for surgery. Their clinical efficacy is demonstrated after 12-6 months of use.

     

    5α-reductase inhibitors (ARI-5) are the first line treatment for men with mild to severe urination disorders with prostate larger than 30 milliliters or PSA levels above 1.5 nanograms per milliliter. After 12-6 months of treatment, PSA values ​​are expected to decline to about half of the value before treatment begins.

     

    The administration of these drugs may reduce the incidence of macroscopic hematuria from the prostate.

     

    Antimuscarinic

    Antimuscarin therapy is an option in men with prostate enlargement who suffer mainly from hoarding symptoms. Medicines from this group improve symptoms. Their clinical efficacy is demonstrated after several weeks. All of these drugs have similar efficacy in the appropriate dosage. They differ in frequency and nature of side effects. It is recommended not to start antimuscarins in patients with residual urine greater than 250 cc.

     

    Phosphodiesterase inhibitors 5 (PDE5)

    Daily treatment with phosphodiesterase 5 inhibitors is an option in men with prostate enlargement who suffer from urinary disorders. This group of drugs improves symptoms, and their clinical efficacy is demonstrated after several weeks.

     

    These drugs are prohibited for use in patients taking nitrates, in patients with Unstable Angina, a recent heart attack (3 months), recent stroke (6 months), congestive heart failure, kidney failure, or severe liver failure in patients with non-arteritic anterior ischemic optic neuropathy (NAION) and in patients taking doxazosin or terazosin α blockers.

     

    Desmopressin

    In patients with prostatic hyperplasia who suffer from urinary tract disorders and especially nocturnal polyuria, desmopressin may be considered. Desmopressin reduces the volume of urine production at night. Take the medicine before bedtime and avoid drinking an hour before taking it and 8 hours later. The drug can cause hyponatremia, which increases with age and, accordingly, requires sodium monitoring in the blood.

     

    Combined drug therapy

    A combination of α-1 adrenergic receptor blockers and AR-5 blockers

    The first-line combination is suitable for treating men with mild to severe urination disorders with prostate larger than 30 milliliters or PSA levels above 1.5 nanograms per milliliter. Drug combination has been shown to be more effective in preventing disease progression, urinary retention, and the need for prostate surgery than any drug.

     

    Herbal therapy

    Herbal treatment and supplements are not recommended as a standard treatment for BPH. It can be prescribed to a patient who is interested in such treatment and there has no contra-indication.

     

    Intrusive treatments

    Surgery

    Surgery is an immediate solution to bladder obstruction and disorders caused by BPH.

     

    The choice of surgical method depends on the size of the prostate, the experience and preference of the surgeon, the risk factors for surgery, and the patient's preference.

     

    Absolute indications for surgery: Urinary retention after unsuccessful withdrawal from catheter, urinary retention in the presence of an selling of the kidney collecting ducts and kidney failure.

     

    Relative indications for surgery: failure of drug therapy, urinary infections as a complication of BPH, recurrent urinary bleeding due to BPH that did not respond to drug therapy, and stones in the bladder.

     

    The patient may choose the surgical treatment as the first treatment option, after he has been presented with all the treatment options and the advantages and disadvantages of the various treatments have been presented to him.

     

    Changes in prostate size during urological follow-up, large urine residues, increased PSA values, slow urinary flow, and adult age are risk factors for BPH progression, but they are not an absolute indication of surgery.

     

    Types of surgery

    TURP (Trans Urethral Resection of the Prostate): Standard prostate surgery is less than 80 cc

    TUIP (Trans Urethral Incision of the Prostate): Preserved as a treatment for a prostate less than 30 cc, provided that there is no enlarged middle lobe, this has a reduced chance of developing a complication of ejaculation and an increased likelihood of future surgical intervention.

    SPP / RPP (Prostatectomy / Retro Pubic Prostatectomy): Open-access surgery is recommended as a large prostate surgery or surgery that requires opening the bladder (such as removing a bladder section or removing a large stone from the bladder)

    TUVP (Electrical, Trans Urethral Vaporization of the Prostate): A therapeutic alternative to TURP / TUIP

    Laser Prostatectomy (HoLP = Holmium Laser Resection of the Prostate, HoLEP = Holmium Laser Enucleation of the Prostate) can be used as a therapeutic alternative to TURP or SPP / RPP.

     

    Minimally invasive treatments

    TUMT (Trans Urethral Microwave Thermotherapy), TUNA (Transurethral needle ablation), VLAP (Visual laser ablation of the prostate), ILC (Intersitial Laser Coagulation) are all types of minimally invasive treatments, some of which can be performed in an ambulatory manner.

     

    Those that can be performed under local anesthesia are suitable for patients with high surgical risk.

     

    None of the methods demonstrated an advantage in improving long-term symptoms compared with standard surgical treatment.

     

    Follow-up after treatment

    The monitoring tools will be determined based on the type of treatment the patient receives, the severity of his symptoms, his character and his response to the treatment.

     

    Change lifestyle only

    Re-evaluation after 6 months to check whether the patient condition is stable and did not change for the worse.

     

    Treatment of alpha blockers with and without combination with other drugs

    Re-evaluation after 4-6 weeks of treatment. If the treatment helps and there are no side effects that warrant a change in treatment - it is recommended to follow up after 6 months. If the situation is stable continue an annual follow up.

     

     

    Summary

    Urinary symptoms in men with benign prostatic hyperplasia are common in men over the age of 40. It affects the quality of life of patients. The goal is to identify the cause of the disorders, changing lifestyle habits, prescribing proper medications, as well as invasive medical treatment such as surgery to improve the quality of life of the patients and prevent the progression of the symptoms.