Advances in the Management of BPH

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. Storage Symptoms Frequency Nocturia Urgency Urge incontinence Bladder Pain Understanding Lower Urinary Tract Symptoms (after Abrams, Bristol, UK) • 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 specificfor 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