Advances in the Management Advances in the Management of BPHof BPH

Mr C DawsonMr C Dawson

Consultant UrologistConsultant Urologist

Edith Cavell HospitalEdith Cavell Hospital

PeterboroughPeterborough

Advances in the Management Advances in the Management of BPHof BPH

Mr C DawsonMr C Dawson

Consultant UrologistConsultant Urologist

Fitzwilliam HospitalFitzwilliam Hospital

PeterboroughPeterborough

The Scale of the ProblemThe Scale of the Problem

Moderate to severe Lower Urinary Tract Moderate to severe Lower Urinary Tract Symptoms (LUTS) occur in 25% of men Symptoms (LUTS) occur in 25% of men over 50 years, and the incidence rises with over 50 years, and the incidence rises with ageage

Approximately 90% of men will develop Approximately 90% of men will develop histological evidence of BPH by 80 years of histological evidence of BPH by 80 years of ageage

The Scale of the ProblemThe Scale of the Problem

Increasing because:Increasing because: Men are living longerMen are living longer Proportion of Men over 50 years will Proportion of Men over 50 years will

increaseincrease Men are better informed about health Men are better informed about health

mattersmatters

Difficulties in Diagnosis and Difficulties in Diagnosis and ManagementManagement

The symptoms of BPH are the same as The symptoms of BPH are the same as those of early Prostate Cancerthose of early Prostate Cancer

Confirmation of the presence of prostate Confirmation of the presence of prostate cancer may be difficultcancer may be difficult

The need to treat (proven) cancer may not The need to treat (proven) cancer may not always be clear cutalways be clear cut

Understanding Lower Urinary Understanding Lower Urinary Tract Symptoms Tract Symptoms (after Abrams, Bristol, UK)(after Abrams, Bristol, UK)

Storage SymptomsStorage Symptoms FrequencyFrequency NocturiaNocturia UrgencyUrgency Urge incontinenceUrge incontinence Bladder PainBladder Pain

D e tru so r In sta b i li ty B lad de r H yp erse n sit iv i ty B lad d er O u tle t O b stru ction D e tru so r F a ilu re

Voiding Symptoms Slow stream Intermittent flow Hesitancy Straining Terminal dribble

Physical SignsPhysical Signs

May be fewMay be few Look for obvious uraemiaLook for obvious uraemia Palpate for full bladderPalpate for full bladder Examine urethral meatus and palpate Examine urethral meatus and palpate

urethra for strictureurethra for stricture DIGITAL RECTAL EXAMINATION DIGITAL RECTAL EXAMINATION

(DRE) !!(DRE) !!

Investigations for BPHInvestigations for BPH

Urea and electrolytes if clinically indicatedUrea and electrolytes if clinically indicated PSA (should we counsel patients?)PSA (should we counsel patients?) Ultrasound urogramUltrasound urogram Flow rate (if you have access)Flow rate (if you have access) IPSSIPSS

IPSS IPSS

A word about Prostate CancerA word about Prostate Cancer

No symptoms No symptoms specificspecific for early prostate for early prostate cancercancer

Presenting symptoms are therefore those of Presenting symptoms are therefore those of BPHBPH

Biopsy of the prostate should be performed Biopsy of the prostate should be performed in those with abnormal DRE, or PSA above in those with abnormal DRE, or PSA above age-specific reference rangeage-specific reference range

Prostate Specific AntigenProstate Specific Antigen

Single-chain glycoprotein of 240 aa Single-chain glycoprotein of 240 aa residues and 4 carbohydrate side chainsresidues and 4 carbohydrate side chains

Physiological role in lysis of seminal Physiological role in lysis of seminal coagulumcoagulum

Prostate specific, but Prostate specific, but NOTNOT cancer specific cancer specific

Prostate Specific AntigenProstate Specific Antigen

In In additionaddition to prostate cancer, an elevated level may to prostate cancer, an elevated level may be found inbe found in

Increasing ageIncreasing age Acute urinary retention / CatheterisationAcute urinary retention / Catheterisation after TURP / Prostate Biopsyafter TURP / Prostate Biopsy ProstatitisProstatitis BPHBPH

A reduced level may be found in patients treated A reduced level may be found in patients treated with with FinasterideFinasteride

The Problem with PSAThe Problem with PSA

Men with Prostate Cancer may have a Men with Prostate Cancer may have a normalnormal PSAPSA

Men with BPH or other benign conditions may Men with BPH or other benign conditions may have a have a raisedraised PSA PSA

May not even be prostate-specific!May not even be prostate-specific! What to do with men with a PSA of 4-10 ng/mlWhat to do with men with a PSA of 4-10 ng/ml

PSAPSA = = PPersistent ersistent SSource of ource of AAnxiety?nxiety?

Refinements in the use of PSARefinements in the use of PSA

PSA densityPSA density PSA VelocityPSA Velocity Age-Specific PSAAge-Specific PSA

40-49 Years old40-49 Years old <2.5ng/ml<2.5ng/ml

50-59 Years old50-59 Years old <3.5ng/ml<3.5ng/ml

60-69 Years old60-69 Years old <4.5ng/ml<4.5ng/ml

70-79 Years old70-79 Years old <6.5ng/ml<6.5ng/ml

Free:Total PSA ratio (<0.15 strongly suggests Free:Total PSA ratio (<0.15 strongly suggests possibility of Ca Prostate)possibility of Ca Prostate)

Prostate Specific AntigenProstate Specific Antigen

PPossiblyossibly

SSomeome

AAttributesttributes

The Management of BPHThe Management of BPH

Advances in the Advances in the Management of Management of BPHBPH

New treatment modalities for BPHNew treatment modalities for BPH

-blocker therapy (including selective blockers of -blocker therapy (including selective blockers of --1a receptors)1a receptors)

5- 5- -reductase inhibitors - Finasteride (Proscar)-reductase inhibitors - Finasteride (Proscar) Minimally invasive TechniquesMinimally invasive Techniques

– Transurethral Microwave Thermotherapy (TUMT)Transurethral Microwave Thermotherapy (TUMT)

– Transurethral Needle ablation (TUNA)Transurethral Needle ablation (TUNA)

– Transrectal high-intensity focused ultrasound (HiFU)Transrectal high-intensity focused ultrasound (HiFU)

– Transurethral electrovaporisation (TUVP)Transurethral electrovaporisation (TUVP)

Pharmacotherapy for BPHPharmacotherapy for BPH

Alpha-blockers remain an important Alpha-blockers remain an important therapytherapy

Selective Selective -1a receptor blockers -1a receptor blockers maymay have have fewer side effectsfewer side effects

Alpha blocker therapyAlpha blocker therapy

Pharmacotherapy for BPHPharmacotherapy for BPH

Finasteride (Proscar) - PLESS study has Finasteride (Proscar) - PLESS study has confirmed that men with large prostates confirmed that men with large prostates (>40cc), taking long-term therapy, less (>40cc), taking long-term therapy, less likely to develop acute retention, or require likely to develop acute retention, or require surgical interventionsurgical intervention

Minimally invasive therapiesMinimally invasive therapies

High energy TUMT, and TUNA, have proven High energy TUMT, and TUNA, have proven clinical efficacy between that of drug therapy clinical efficacy between that of drug therapy and TUVP or laser therapyand TUVP or laser therapy

HiFU currently requires GA, is costly and time HiFU currently requires GA, is costly and time consuming, and appears unlikely to be popular at consuming, and appears unlikely to be popular at presentpresent

The subjective response after MITs and TURP The subjective response after MITs and TURP appear similar, but objective results superior for appear similar, but objective results superior for TURPTURP

Surgical TherapiesSurgical Therapies

TURP still the gold standard therapy, with TURP still the gold standard therapy, with which all other therapies must be which all other therapies must be consideredconsidered

Laser therapy Laser therapy – expensive to set upexpensive to set up– Significantly reduced blood loss Significantly reduced blood loss – Catheter may be required post operativelyCatheter may be required post operatively

Open Prostatectomy rarely requiredOpen Prostatectomy rarely required

ECH Urology Department Guidelines ECH Urology Department Guidelines for the Management of BPHfor the Management of BPH

Produced after discussion between working Produced after discussion between working party of General Practitioners and party of General Practitioners and ConsultantsConsultants

Agreed within the department of UrologyAgreed within the department of Urology

Protocol for the management of Protocol for the management of BPHBPH

E lig ib le fo r S h ared C areProstate C lin ic

Norm al D R E an d P S A

O u tp a tien t ap p t w ithCon su ltan t

Abnorm al D R E an d P S A

R eferra l to U ro log y D ep artm en t M an ag em en t b y G P(See n ext s lid e)

Options

F low ra te an d R es id u a l vo lu m e if p oss ib le

H is to ryIPSS Score

DREU+E an d PSA

GP Assesses Patient

Protocol for the management of Protocol for the management of BPHBPH

SevereIP S S > 2 0

F low ra te < 1 0 m ls /sR es id vo l > 2 0 0 m ls

M oderateIP S S 7 -2 0

F low ra te < 1 5 m ls /sR es id vo l < 2 0 0 m ls

M ildIP S S < 7

F low R ate > 1 5 m ls /sR es id vo l < 1 0 0 m ls

IP S S S core

Refer to the UrologyDepartm ent

alpha-blockers:Refer if no im provem ent

W atchful W aiting

M an ag em en t

Future perspectives for the Future perspectives for the management of BPHmanagement of BPH

Much more emphasis on Much more emphasis on Quality of LifeQuality of Life Minimally invasive therapies are improving Minimally invasive therapies are improving

and may yet challenge the superiority of and may yet challenge the superiority of TURPTURP

Conclusions - BPHConclusions - BPH

Remains an important cause of patient Remains an important cause of patient morbiditymorbidity

Correct approach to assessment is importantCorrect approach to assessment is important Many men may have their symptoms relieved Many men may have their symptoms relieved

by alpha blocker therapy or Finasteride, which by alpha blocker therapy or Finasteride, which has also been shown to reduce the likelihood has also been shown to reduce the likelihood of surgery or acute urine retentionof surgery or acute urine retention

Conclusions - BPHConclusions - BPH

A large variety of MITs exist for BPH who A large variety of MITs exist for BPH who fail drug therapy, but for most patients the fail drug therapy, but for most patients the gold standard surgical procedure remains gold standard surgical procedure remains TURPTURP

The next few years will see many more The next few years will see many more techniques available to challenge the techniques available to challenge the position of TURPposition of TURP

Thank you for your attentionThank you for your attention