Benign Prostatic Hyperplasia (BPH)

1

• Benign Prostatic Hyperplasia (BPH)
• Patient Evaluation and Diagnosis

2
BPH Diagnosis and Treatment Algorithm

• Initial Evaluation
• History
• DRE Focused PE
• Urinalysis
• PSA

• Presence of
• Refractory retention or any of the following
  clearly related to BPH
• Persistent gross hematuria
• Bladder stones
• Recurrent UTIs
• Renal insufficiency

AUA/IPSS Symptom Index Assessment of Patient
Bother
Moderate/Severe Symptoms (AUA/IPSS 8)
Mild Symptoms (AUA/IPSS 7) or No Bothersome
Symptoms
Surgery

• Optional Diagnostic Tests
• Uroflow
• PVR

Discussion of Treatment Options

• Optional Diagnostic Tests
• Pressure flow
• Urethrocystoscopy
• Prostate ultrasound

Patient Chooses Noninvasive Therapy
Patient Chooses Invasive Therapy
Medical Therapy
Watchful Waiting
Minimally Invasive Therapies
Surgery
AUA Guideline 2003/updated 2006.
3
Initial Evaluation

• Detailed medical history
• DRE and focused physical exam
• Urinalysis
• PSA in selected patients
• Symptom assessment
• AUA/IPSS Symptom Index
• Assessment of patient bother

DRE - digital rectal exam PSA - prostate-specific
antigen Per physicians clinical judgment
AUA Guideline 2003/updated 2006.
4
Further Evaluation Warranted?

• Abnormal DRE
• Abnormal PSA
• Prior therapy for LUTS/BPH
• Non-response to medical therapy
• lt50 years of age

• History of diabetes
• History of pelvic surgery/ trauma
• Neurologic symptoms/ disease
• Renal insufficiency

AUA Guideline 2003/updated 2006.
5
Questions to Ask Relative to History

• Medications affecting voiding
• Antihistamines
• Decongestants
• Diseases
• Diabetes
• Congestive heart failure
• Neurologic

• Oral intake
• Timing
• Caffeine
• Alcohol
• Medications affecting volume
• Diuretics
• Stool-bulking agents

AUA Guideline 2003/updated 2006.
6
Optional Diagnostic Tests

• Following initial evaluation
• Uroflow
• Urinary flow-rate recording (Qmax)
• PVR
• If patient chooses invasive therapy
• Pressure flow
• Urethrocystoscopy
• Prostate ultrasound

AUA Guideline 2003/updated 2006.
7
Standard Questionnaires for Patients Perception
of BPH Symptoms

• AUA Symptom Score
• International Prostate Symptom Score (IPSS)
• BPH Impact Index (Bother Score)

8
AUA Symptom Score Index

• Seven-item questionnaire related to BPH symptoms
• Validated and reproducible
• Determines disease severity
• Documents response to therapy
• Allows standardized comparisons of symptom relief
  when evaluating treatments

AUA Guideline 2003/updated 2006.
9
AUA Symptom Score
AUA Guideline 2003/updated 2006.
10
Classification of AUA Symptom Scores

• The possible total runs from 0-35 points with
  higher scores indicating more severe symptoms.
  Scores lower than 7 are considered mild and
  generally do not warrant treatment.
• Classification ranges
• Mild (0-7)
• Moderate (8-19)
• Severe (20-35)
• Without bother or bothersome

AUA Guideline 2003/updated 2006.
11
Initial Management and Discussion Using AUA
Symptom Score

• Patients with mild symptoms (AUA symptom score
  7)
• and
• Patients with moderate or severe symptoms (AUA
  symptom score 8) who are not bothered by their
  symptoms
• Offer watchful waiting
• Reassure patient
• Reassess periodically

12
Initial Management and Discussion Using AUA
Symptom Score

• Patients with bothersome, moderate to severe
  symptoms (AUA Symptom Score 8)
• Watchful waiting
• Discuss BPH treatment options, including benefits
  and risks
• Provide patient education materials

13
International Prostate Symptom Score (IPSS)

• AUA Symptom Score Index plus additional question
  on QOL as a function of urinary symptoms
• If you were to spend the rest of your life with
  your urinary condition just the way it is now,
  how would you feel about that?
• Scale of 0 to 6 (delighted to terrible)
• Note While symptoms may be prevalent, they may
  not be troublesome

OLeary MP. Urology. 2000.
14
BPH Impact Index (Bother Score)
None Only a little Some A lot
1. Over the past month, how much physical
discomfort did any urinary problems cause you?
2. Over the past month, how much did you worry
about your health because of any urinary problems?
Not at all Bothers Bothers Bothers bothersome
me a little me some me a lot
3. Overall, how bothersome has any troublewith
urination been during the past month?
None of A little of Some of Most of All of
the time the time the time the time the time
4. Over the past month, how much of the timehas
any urinary problem kept you from doing the kinds
of things you would usually do?
AUA Guideline 2003/updated 2006.
15
References

• American Urological Association Education and
  Research, Inc. AUA Guideline 2003/Updated 2006.
• Barry MJ, Fowler FJ, OLeary MP et al. The
  American Urological Association Symptom Index for
  benign prostatic hyperplasia, J Urol.
  19921481549-1557.
• OLeary MP. LUTS, ED, QOL alphabet soup or real
  concerns to aging men? Urology, 200056(suppl
  5A)7-11.
• For more information about PROSTIVA RF Therapy,
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