BPH

Table 1: Treatment Options for Benign Prostatic Hyperplasia

• SYMPTOMS OF BPH
  • Lower Urinary Tract Symptoms
    • The symptoms related to bladder outlet obstruction due to BPH have in the past arbitrarily been described as a group as "prostatism"
    • Categorized as
      • Obstructive symptoms
        • Impairment in the size/force of the urinary stream
        • Hesitancy and/or abdominal straining
        • Intermittent or interrupted flow
        • A sensation of incomplete emptying
      • Irritative symptoms
        • Nocturia
        • Daytime frequency
        • Urgency
        • Urge incontinence
        • Dysuria. .
    • LUTS (lower urinary tract symptoms) is a rubric, introduced by Abrams, to replace the term "prostatism," as well the terminology of "irritative" and "obstructive" symptoms
      • Filling and storage symptoms
      • Voiding (emptying) symptoms
• SIGNS OF BPH
  • Detectable anatomic enlargement of the prostate on physical examination or imaging
    • Tthere is no clear relationship between the degree of anatomic enlargement and the severity of symptoms or the degree of urodynamic changes.
  • Bladder changes secondary to obstruction can occur.
    • Bladder wall thickening
    • Trabeculation (which are also associated with involuntary bladder contractions)
    • Bladder diverticula (which could also be congenital).
    • Bladder calculi
    • Bladder decompensation can occur, and gross bladder distention can result
    • Chronically increased residual urine volumes
    • Persistent urinary infection
    • Acute urinary retention may supervene
    • Azotemia
    • Upper tract changes.
      • Ureterectasis, hydroureter, and/or hydronephrosis
• URODYNAMICS OF BPH
  • Decreased mean and peak flow rates, an abnormal flow pattern characterized by a long low plateau
  • Elevated detrusor pressures at the initiation of and during flow
  • May or may not have increased residual urine
  • 50 percent of BPH patients are found to have bladder hyperactivity during filling.
    • Pressure flow urodynamics are necessary to distinguish between patients with obstructive BPH and patients who have inadequate detrusor contractility, the symptoms of which may be identical.
  • Successful treatment of BPH by prostatectomy is generally correlated with a reduction in the detrusor pressure (PDET) during an increased uroflow.
• EVALUATION OF LUTS SUSPECTED TO BE DUE TO BPH
  • The essentials of the initial evaluation include:
    • History
    • Digital rectal and focused physical examinations
    • Urinalysis
    • Urine cytology in those with significant irritative symptoms
    • Serum creatinine
    • Renal ultrasound (if creatinine abnormal)
    • A standardized symptom assessment, such as the AUA symptom index
    • "Routine PSA measurement" in this population has been a source of active debate.
      • The AHCPR guidelines list PSA measurement as optional, whereas the International Consultation on BPH recommends it.
  • In patients with more severe symptoms or who are being considered for active treatment, urodynamics may be desirable
    • The simplest of these, flowmetry and residual urine volume, are recommended by the International Consultation
  • Endoscopic examination of the lower urinary tract should be performed if other lower urinary tract pathology is suspected and is recommended prior to invasive treatment
• INDICATIONS FOR TREATMENT OF CLINICAL BPH
  • Indications for surgery has varied widely over time, and the current climate is much more conservative than existed 10 to 20 years ago.
  • Certain absolute or near absolute indications exist
    • Refractory or repeated urinary retention
    • Azotemia due to BPH
    • Significant recurrent gross hematuria
    • Recurrent or residual infection due to BPH
    • Bladder calculi
    • A large residual urine
    • Overflow incontinence
    • Large bladder diverticula due to BPH.
  • Without an absolute or near absolute indication, or combinations of these, the bothersome nature of the symptomatology is generally what prompts the patient to request, or the physician to suggest, treatment. Pathologic urodynamic findings may certainly be influential as well.

Male LUTS - THE NEUROUROLOGIC EVALUATION

History Bladder diary
Quality of life assessment
Physical examination
Neurologic examination
Urine bacteriologic studies
Renal function studies
Radiologic evaluation

• Upper tract
• Lower tract Urodynamic/video-urodynamic study

• History
  • Symptomatology
    • Abnormality of storage, emptying, or both History of the symptoms and their onset, duration, time course, and relationship to neurologic Disease or other neurologic symptoms
• Physical and Neurologic Evaluation
  • General physical examination
  • Focused physical examination
    • Lower abdomen, genitalia, and rectum
    • Prostate abnormalities must be detected
  • Neurologic examination
    • Neurologic lesion
      • Localizes it in an attempt to corroborate and explain a given voiding dysfunction
    • Mental status
      • Level of consciousness, orientation, speech, comprehension, and memory
        • Senile and presenile dementia, brain tumors, and normal pressure hydrocephalus
    • Motor function and coordination
      • Sensory examination - touch, pain, temperature, vibration, and position
      • Deep tendon reflexes
        • Lower motor neuron (LMN) lesion
        • Upper motor neuron (UMN) lesion
• Radiologic Evaluation
  • Upper tracts
    • Ultrasonography
      • Hydronephrosis
      • Hydroureter
        Upper tract imaging is generally recommended only in specific situations in the adult:
        • Decreased bladder compliance
        • Neurogenic incontinence
        • Severe urethral obstruction
        • Incontinence associated with significant post void residual
        • Coexisting loin and flank pain
        • Suspected extra-urethral urinary incontinence
  • Lower tracts
    • Cystogram
      • Cystourethrographic patterns caused by neuromuscular disease
• Endoscopic Evaluation
  • Recommended in specific situations in the adult:
    • When initial testing suggests other types of pathology
      • Microscopic gross hematuria
      • Pain
      • Discomfort
      • Persistent or severe symptoms of bladder overactivity
      • Suspected extra-urethral incontinence
    • In patients who have previously undergone bladder, prostate, or other pelvic surgery
      In men with incontinence
• Urodynamic/Video Urodynamic Evaluation
  • Urodynamics Simplified
    
    
    ^1,2Total bladder (Pves) and detrusor (Pdet) pressures during a filling cystometrogram (FCMG)
    ³Filling cystometrogram
    ⁴Detrusor leak point pressure
    ⁵Urethral pressure profilometry
    ⁷Fluoroscopy of outlet during filling/storage
    ^{1a, 2a}Total bladder and detrusor pressures during a voiding cystometrogram (VCMG)
    ⁸Voiding cystometrogram
    ⁹Micturitional urethral pressure profilometry
    ¹⁰Fluoroscopy of outlet during emptying
    ¹¹Electromyography of periurethral striated musculature
    ¹²Flowmetry
    ¹³Residual urine
    
    
    
  • General
  • Flowmetry
  • Residual urine volume
    • Measured directly
    • Estimated by cystography or ultrasonography
  • Filling cystometry
  • Voiding cystometry, combined pressure studies, video urodynamic studies
  • Electromyography
  • Urethral profilometry
  • Ambulatory urodynamics
• Voiding Dysfunction in Neurologic Injury and Disease
  • Neurourologic evaluation
    • History
      • Current urological symptoms
        • Enuresis, F, U, UI, BOO, UTI, etc.
      • Past GU, Med, Surg Hx
        • Similar past symptomatology
        • Prior neurologic, pelvic surgery
        • Prior bladder or urethral surgery
        • Associated bowel/sexual symptoms
        • Medications
      • Limitations
        • Hands/dexterity
        • Mobility
        • Environment: Supportive care, caregivers, etc
        • Other medical issues: PROGNOSIS from neuro dz
      • Physical examination
        • Neurologic examination
      • PVR
      • Creatinine/renal fxn studies
      • Urine bacteriologic studies
      • Upper tract study
      • Urodynamic evaluation
        • Utility in prognosis and treatment
          • Presenting LUTS do not correlate well with of type, extent or level of injury/disease…..or UDS findings
          • Severity of symptoms and PE do not correlate well with prognosis or "danger" to upper tracts…..or UDS findings
          • In SCI, level of injury not always predictive of UDS*
            • Correlation of imaging and UDS not exact
          • Therefore management often dictated by UDS
          • Detrusor leak point pressure
            • Measurement of the resistance of the urethral outlet (sphincter) to detrusor pressure as an expulsive force
            • THIS IS NOT (AND SHOULD BE CLEARLY DIFFERENTIATED FROM) A VALSALVA LEAK POINT PRESSURE OR VLPP
            • Assessing risk to upper tracts
              • Poor compliance
              • Myelo, XRT, s/p APR, etc.
          • +/- VCUG
          • +/- Endoscopic evaluation

References

• Abrams P: In support of pressure-flow studies for evaluating men with lower urinary tract symptoms. Urology 44:153-155, 1994.
• Ball AJ, Fenely RCL, Abrams PH: The natural history of untreated "prostatism " Br J Urol 53:613-616, 1981.
• Barry MJ: Epidemiology of benign prostatic hyperplasia. AUA Update Series 16:274-279, 1997.
• Barry MJ, Fowler FJ, Bin L, et al: The natural history of patients with benign prostatic hyperplasia as diagnosed by North American urologists. J Urol 157:10-15, 1997.
• Barry MJ, Fowler FJ, Jr., O'Leary MP, and the Measurement Committee of the AUA: The American Urological Association symptom index for benign prostatic hyperplasia. J Urol 148:1549-1557, 1992.
• Barry MJ, Williford WO, Chang Y, et al: Benign prostatic hyperplasia specific health status measures in clinical research: How much change in the AUA symptom index and the BPH impact index is perceptible to patients? J Urol 154:1770-1774, 1995.
• Blaivas J: The bladder is an unreliable witness. Neurourol Urodyn 15:443-445, 1996.
• Denis L, Griffiths K, Khoury S, et al, eds. 4th International Consultation on Benign Prostatic Hyperplasia (BPH). Plymouth, United Kingdom, Plymbridge Distributors, Ltd., 1998.

  Chapter 3: Regulation of prostatic growth. Cockett ATK, Coffey D, DiSant Agnese A, et al.
  Chapter 5: Initial evaluation of LUTS. Artibani W, Correa R, Desgranchamps F, et al.
  Chapter 6: Quantification of symptoms, quality of life and sexuality. Adolfsson J, Barry M, Batista JE, et al.
  Chapter 7: The urodynamics of LUTS. Abrams P, Buzelin JM, Griffiths D, et al.
  Chapter 10: Interventional therapy. Altwein J, Baba S, Blute M, et al. Chapter 11: Endocrine treatment. Akaza H, Bartsch G, Calais daSilva F, et al. Chapter 12: Alpha-blocker therapy. AldoBono V, Andersson KE, Chapple C, et al.
  Chapter 15: BPH 1997-New treatment strategy. ElHilali M, Kirby R, McConnell J.
  Lepor H, Williford WO, Barry MJ, et al: The efficacy of terazosin, finasteride, or both in BPH. N Engl J Med 335:533-539, 1996.

• McConnell J: Why pressure flow studies should be optional and not mandatory for evaluating men with benign prostatic hyperplasia. Urology 44:156-158, 1994.
• McConnell JD, Barry MJ, Bruskewitz R, et al: Benign prostatic hyperplasia: Diagnosis and treatment. Clinical Practice Guideline, no. 8, AHCPR publication No. 94-0582, Rockville, Md., Agency for Health Care Policy Research, Public Health Service, US Dept. Of Health and Human Services, 1994.
• Walsh PC, Retik AB, Vaughan ED Jr., Wein AJ, eds: Campbell's Urology, 7th ed. Philadelphia, Saunders Company, 1998. Chapter 45: The molecular biology, endocrinology, and physiology of the prostate and seminal vesicles. Partin AW, Coffey DS.

  Chapter 46: Epidemiology, etiology, pathophysiology, and diagnosis of benign prostatic hyperplasia. McConnell JD.
  Chapter 47: Natural history, evaluation, and nonsurgical management of benign prostatic hyperplasia. Lepor H.
  Chapter 48: Minimally invasive treatment of benign prostatic hyperplasia. McCullough DL.
  Chapter 49: Transurethral surgery. Mebust WK.

• Wasson JH, Reda DJ, Bruskewitz RC, et al: A comparison of transurethral surgery with watchful waiting for moderate symptoms of BPH. N Engl J Med 332:75-79,1995.
• Wein AJ: Criteria for assessing outcome following intervention for benign prostatic hyperplasia. In: Lepor H, ed. Prostatic Diseases. Philadelpha, Saunders, 1999, pp 210-231.

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