advances in the management of bph mr c dawson consultant urologist edith cavell hospital...
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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