Benign prostatic hyperplasia (BPH)

Guideline
The Agency for Healthcare Research and Quality's (AHRQ) is one of 12 agencies within
the United States Department of Health and Human Services (HHS). The agency originally began
as the Agency for Health Care Policy and Research and was tasked with producing guidelines.

Its mission is to produce evidence to make health care safer, higher quality, more accessible,
equitable, and affordable, and to work within the U.S. Department of Health and Human Services
and with other partners to make sure that the evidence is understood and used.

Introduction:
The term "lower urinary tract symptoms," or LUTS, is nonspecific. It has been used as a general
term to refer to any combination of urinary symptoms or as a more specific term to refer to
those symptoms primarily associated with overactive bladder (frequency, urgency, and
nocturia), It has also been commonly referred to as prostatism.
Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic
diagnosis characterized by proliferation of the cellular elements of the prostate. Chronic
bladder outlet obstruction (BOO) secondary to BPH may lead to urinary retention, renal
insufficiency, recurrent urinary tract infections, gross hematuria, and bladder calculi.
When the prostate enlarges, it may constrict the flow of urine. Nerves within the prostate and
bladder may also play a role in causing the following common symptoms:
-Urinary frequency.
-Urinary urgency.
-Hesitancy : Difficulty initiating the urinary stream; interrupted, weak stream.
- Incomplete bladder emptying : The feeling of persistent residual urine, regardless of the
frequency of urination.
- Straining : The need strain or push (Valsalva maneuver) to initiate and maintain urination in
order to more fully evacuate the bladder.
- Decreased force of stream :The subjective loss of force of the urinary stream over time.
Dribbling: The loss of small amounts of urine due to a poor urinary stream.

The diagnostic criteria:

-Digital rectal examination
The digital rectal examination (DRE) is an integral part of the evaluation in men with presumed
BPH.
-Laboratory studies

 Urinalysis : Examine the urine using dipstick methods and/or via centrifuged sediment
evaluation to assess for the presence of blood, leukocytes, bacteria, protein, or glucose.
 Urine culture :This may be useful to exclude infectious causes of irritative voiding .
 Prostate-specific antigen.
 Electrolytes, blood urea nitrogen (BUN), and creatinine : These evaluations are useful
screening tools for chronic renal insufficiency in patients who have high postvoid
residual (PVR) urine volumes.

- Ultrasonography

Ultrasonography (abdominal, renal, transrectal) and intravenous urography are useful for
helping to determine bladder and prostate size and the degree of hydronephrosis in patients
with urinary retention or signs of renal insufficiency.

-Endoscopy of the lower urinary tract

-Cystoscopy
Cystoscopy may be indicated in patients scheduled for invasive treatment or in whom a foreign
body or malignancy is suspected.

-IPSS/AUA-SI
The severity of BPH can be determined with the International Prostate Symptom Score
(IPSS)/American Urological Association Symptom Index (AUA-SI) plus a disease-specific quality
of life (QOL) question.
Management/Treatment:

The treatment options of lifestyle intervention (fluid intake alteration), behavioral modification
and pharmacotherapy (anticholinergic drugs) should be discussed with the patient.

Non pharmacological therapy:

1. Information on the benefits and harms of benign prostatic hyperplasia (BPH) treatment
options explained to patients considering interventional therapy
2. Watchful waiting Patients with mild symptoms of LUTS secondary to BPH (AUA-SI score
<8) and patients with moderate or severe symptoms (AUA-SI score ≥8) who are not
bothered by their LUTS should be managed using a strategy of watchful waiting.
3. Minimally invasive therapies

 Transurethral needle ablation (TUNA of the prostate is an appropriate and effective

treatment alternative for bothersome moderate or severe LUTS secondary to BPH).

 Transurethral microwave thermotherapy (TUMT is effective in partially relieving

LUTS secondary to BPH and may be considered in men with moderate or severe
symptoms)

4. Surgical procedures

Surgery is recommended for patients who have renal insufficiency secondary to BPH, who
have recurrent UTIs, bladder stones or gross hematuria due to BPH, and those who have
LUTS refractory to other therapies. The presence of a bladder diverticulum is not an
absolute indication for surgery unless associated with recurrent UTI or progressive bladder
dysfunction.

 Open prostatectomy ( is an appropriate and effective treatment alternative for men

with moderate to severe LUTS and/or who are significantly bothered by these
symptoms The choice of approach should be based on the patient's individual
presentation including anatomy, the surgeon's experience, and discussion of the
potential benefit and risks for complications).
 Laser therapies are appropriate and effective treatment alternatives to transurethral
resection of the prostate and open prostatectomy in men with moderate to severe LUTS
and/or those who are significantly bothered by these symptoms
 Transurethral holmium laser ablation/enucleation of the prostate
 Holmium laser resection of the prostate
 Photoselective vaporization of the prostate
  Transurethral incision of the prostate (is an appropriate and effective treatment
alternative in men with moderate to severe LUTS and/or who are significantly
bothered by these symptoms when prostate size is less than 30 mL).
 Transurethral electrovaporization of the prostate ( is an appropriate and effective
treatment alternative in men with moderate to severe LUTS and/or who are
significantly bothered by these symptoms)
 Transurethral resection of the prostate (is an appropriate and effective primary
alternative for surgical therapy in men with moderate to severe LUTS and/or who
are significantly bothered by these symptoms).

*there is insufficient evidence to recommend using 5-ARIs in the setting of a pre-

TURP to reduce intraoperative bleeding or reduce the need for blood transfusions

Pharmacological therapy:

 Alpha-adrenergic blockers

- Second generation:

 Alfuzosin
 Doxazosin
 Terazosin

*Have Adverse effect like : first-dose syncope, orthostatic hypotension, dizziness

-Third generation:

 Tamsulosin

* good choice if:

1) can not tolerate hypotension

2) severe coronary artery disease

 3) volume depletion

4) cardiac arrhythmias

5) severe orthostasis

6) liver failure

7) taking multiple antihypertensives

8) when the titration would be too complicated for the patient or

produce an unacceptable delay in onset for a particular patient.

Alfuzosin, doxazosin, tamsulosin, and terazosin are appropriate and effective treatment
alternatives for patients with bothersome, moderate to severe LUTS secondary to BPH (AUA-SI
score ≥8). Although there are slight differences in the adverse events profiles of these agents,
all four appear to have equal clinical effectiveness. As stated in the 2003 Guideline, the
effectiveness and efficacy of the four alpha blockers under consideration appear to be similar.
Although studies directly comparing these agents are currently lacking, the available data
support this contention.

 5-Alpha-reductase inhibitors (5-ARIs)

 Dutasteride
 Finasteride

* first choice for:

- a significantly enlarged prostate (>40 g)
- and can not tolerate the cardiovascular adverse effects of alpha 1-
adrenergic antagonists.

*peferred for patients with BPH and an enlarged prostate gland who have:
- uncontrolled arrhythmias
- poorly controlled angina
- taking multiple antihypertensive agents

- unable to tolerate hypotensive adverse effects of alpha 1-adrenergic antagonists.

* 5-ARIs may be used to prevent progression of LUTS secondary to BPH and to reduce the risk
of urinary retention and future prostate-related surgery.

* The 5-ARIs are appropriate and effective treatment alternatives for men with LUTS secondary
to BPH who have demonstrable prostate enlargement.

*Finasteride is an appropriate and effective treatment alternative in men with refractory

hematuria presumably due to prostatic bleeding (i.e., after exclusion of any other causes of
hematuria). A similar level of evidence concerning dutasteride was not reviewed

 Combination therapy
 Alpha-blocker and 5-ARI

*if enlarged prostate gland > 40 g & an elevated PSA ≥ 1.4 ng/mL (1.4 mc/L)

*The combination of an alpha-blocker and a 5-alpha reductase inhibitor (5-ARIs) (combination

therapy) is an appropriate and effective treatment for patients with LUTS associated with
demonstrable prostatic enlargement based on volume measurement, prostate-specific antigen
(PSA) level as a proxy for volume, and/or enlargement on digital rectal exam (DRE).

 Anticholinergic agents
 Oxybutynin
 Tolterodine

*patient still complain of irritative voiding symptoms (e.g., urinaryfrequency, urgency) after
alpha 1-adrenergic antagonist, 5 alpha-reductase inhibitor,
or surgery

*Anticholinergic agents are appropriate and effective treatment alternatives for the
management of LUTS secondary to BPH in men without an elevated post-void residual and
when LUTS are predominantly irritative.

*Prior to initiation of anticholinergic therapy, baseline PVR urine should be assessed.

 *Anticholinergic should be used with caution in patients with a post-void residual greater
than 250 to 300 mL.

PREPARED By : Pharm.Ds:

1- Enam Rashdan
2- Doaa Hazmi
3- Esraa Ababneh
Reviewed By:
Pharm.D : Neda Rwash
2/11/2014