1. Advances in the Management of BPH
Mr C Dawson
Consultant Urologist
Edith Cavell Hospital
Peterborough

2. Advances in the Management of BPH
Mr C Dawson
Consultant Urologist
Fitzwilliam Hospital
Peterborough

3. The Scale of the Problem
Moderate to severe Lower Urinary Tract Symptoms (LUTS) occur in 25% of men over 50 years, and the incidence rises with age
Approximately 90% of men will develop histological evidence of BPH by 80 years of age

4. The Scale of the Problem
Increasing because:
Men are living longer
Proportion of Men over 50 years will increase
Men are better informed about health matters

5. Difficulties in Diagnosis and Management
The symptoms of BPH are the same as those of early Prostate Cancer
Confirmation of the presence of prostate cancer may be difficult
The need to treat (proven) cancer may not always be clear cut

6. Understanding Lower Urinary Tract Symptoms (after Abrams, Bristol, UK)
Storage Symptoms
Frequency
Nocturia
Urgency
Urge incontinence
Bladder Pain
Voiding Symptoms
Slow stream
Intermittent flow
Hesitancy
Straining
Terminal dribble

7. Physical Signs May be few Look for obvious uraemia
Palpate for full bladder
Examine urethral meatus and palpate urethra for stricture
DIGITAL RECTAL EXAMINATION (DRE) !!

8. Investigations for BPH
Urea and electrolytes if clinically indicated
PSA (should we counsel patients?)
Ultrasound urogram
Flow rate (if you have access)
IPSS

9. IPSS

10. A word about Prostate Cancer
No symptoms specific for early prostate cancer
Presenting symptoms are therefore those of BPH
Biopsy of the prostate should be performed in those with abnormal DRE, or PSA above age-specific reference range

11. Prostate Specific Antigen
Single-chain glycoprotein of 240 aa residues and 4 carbohydrate side chains
Physiological role in lysis of seminal coagulum
Prostate specific, but NOT cancer specific

12. Prostate Specific Antigen
In addition to prostate cancer, an elevated level may be found in
Increasing age
Acute urinary retention / Catheterisation
after TURP / Prostate Biopsy
Prostatitis
BPH
A reduced level may be found in patients treated with Finasteride

13. The Problem with PSA Men with Prostate Cancer may have a normal PSA
Men with BPH or other benign conditions may have a raised PSA
May not even be prostate-specific!
What to do with men with a PSA of 4-10 ng/ml
PSA = Persistent Source of Anxiety?

14. Refinements in the use of PSA
PSA density
PSA Velocity
Age-Specific PSA
40-49 Years old <2.5ng/ml
50-59 Years old <3.5ng/ml
60-69 Years old <4.5ng/ml
70-79 Years old <6.5ng/ml
Free:Total PSA ratio (<0.15 strongly suggests possibility of Ca Prostate)

15. Prostate Specific Antigen
Possibly
Some
Attributes

16. The Management of BPH
Advances in the Management of BPH

17. New treatment modalities for BPH
-blocker therapy (including selective blockers of -1a receptors)
5- -reductase inhibitors - Finasteride (Proscar)
Minimally invasive Techniques
Transurethral Microwave Thermotherapy (TUMT)
Transurethral Needle ablation (TUNA)
Transrectal high-intensity focused ultrasound (HiFU)
Transurethral electrovaporisation (TUVP)

18. Pharmacotherapy for BPH
Alpha-blockers remain an important therapy
Selective -1a receptor blockers may have fewer side effects

19. Alpha blocker therapy

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

21. Minimally invasive therapies
High energy TUMT, and TUNA, have proven clinical efficacy between that of drug therapy and TUVP or laser therapy
HiFU currently requires GA, is costly and time consuming, and appears unlikely to be popular at present
The subjective response after MITs and TURP appear similar, but objective results superior for TURP

22. Surgical Therapies
TURP still the gold standard therapy, with which all other therapies must be considered
Laser therapy
expensive to set up
Significantly reduced blood loss
Catheter may be required post operatively
Open Prostatectomy rarely required

23. ECH Urology Department Guidelines for the Management of BPH
Produced after discussion between working party of General Practitioners and Consultants
Agreed within the department of Urology

24. Protocol for the management of BPH

25. Protocol for the management of BPH

26. Future perspectives for the management of BPH
Much more emphasis on Quality of Life
Minimally invasive therapies are improving and may yet challenge the superiority of TURP

27. Conclusions - BPH Remains an important cause of patient morbidity
Correct approach to assessment is important
Many men may have their symptoms relieved by alpha blocker therapy or Finasteride, which has also been shown to reduce the likelihood of surgery or acute urine retention

28. Conclusions - BPH
A large variety of MITs exist for BPH who fail drug therapy, but for most patients the gold standard surgical procedure remains TURP
The next few years will see many more techniques available to challenge the position of TURP

29. Thank you for your attention