Interpretation by Dr Neil Skolnik from an International Perspective: The Latest AUA Guidelines - Management of BPH/LUTS

Dr.
Neil Skolnik interprets the latest AUA guideline on the management of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH)
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This article organizes Dr.
Neil Skolnik's interpretation for readers' reference! Professor Neil Skolnik BPH is very common, the incidence of BPH in men over 60 years old is about 60%
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BPH generally causes related symptoms through two mechanisms
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One is an enlarged prostate, which usually leads to obstruction of urination, hesitancy to urinate; difficulty urinating; and a weak urine stream
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The second is increased smooth muscle tone in the urethra and bladder, which can lead to symptoms such as urgency, frequency, and nocturia
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Guidelines for the initial assessment of BPH recommend the use of the International Prostate Symptom Score (IPSS) to quantify symptoms and subsequently to track or monitor symptoms
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Have a physical exam, examine the prostate, and do a urinalysis
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Residual urine volume after voiding is considered an optional test
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For mild symptoms, simply limit fluid intake before bed or travel, avoid diuretics as much as possible, reduce caffeine and alcohol intake, and lose weight and exercise to help improve symptoms
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The guidelines clearly point out that no alternative therapy has been found, and randomized controlled studies have found that saw palmetto extract is basically ineffective for this part of patients
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Drug therapy - Alpha-blockers Alpha-blockers are a good first-choice therapy
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All alpha-blockers have roughly the same efficacy, but have a different spectrum of adverse effects
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Terazosin and doxazosin can cause orthostatic hypotension; tamsulosin and silodosin have the highest likelihood of ejaculatory dysfunction; alfuzosin has the lowest incidence of ejaculatory dysfunction
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Treatment of patients with benign prostatic hypertrophy If an enlarged prostate, defined as >30cc on digital rectal examination or imaging, or a prostate-specific antigen (PSA) level >1.
5 ng/dL, should be treated with a 5-alpha reductase inhibitor, such as Finasteride or dutasteride, alone or in combination with alpha-blockers, are recommended by guidelines
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Studies have shown that 5-alpha reductase inhibitors can reduce prostate size by about 25% over 6 months, which means it takes 6 months or more to relieve symptoms
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In addition, 5-alpha reductase inhibitors can also reduce PSA by about 50%
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It is important to emphasize that if PSA testing is chosen to screen for prostate cancer, PSA levels must be doubled when assessing prostate cancer risk in people taking 5-alpha reductase inhibitors
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These drugs reduce the need for future prostate surgery and reduce the likelihood of future urinary retention
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Research on the association between 5-alpha reductase inhibitors and cancer risk deserves attention
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The CombAT study showed that 5-alpha reductase inhibitors may reduce the incidence of low-grade and high-grade prostate cancer
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However, some studies have suggested that 5-alpha reductase inhibitors may increase the incidence of high-grade prostate cancer
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Phosphodiesterase-5 Inhibitors (PDE-5) PDE-5 treats erectile dysfunction, such as tadalafil
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Tadalafil can reduce male-related symptoms, regardless of whether the patient has erectile dysfunction, PDE-5 efficacy is about the same as alpha-blockers
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However, when PDE-5 was combined with an alpha-blocker, it did not produce better efficacy
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For men with severe symptoms of urinary retention (urgency and frequency), anticholinergic drugs, such as tolterodine or oxybutynin, can be used alone or in combination with alpha-blockers
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The guidelines state that if anticholinergic drugs are used, the incidence of urinary retention is low (about 1%), but the residual urine volume after voiding needs to be measured
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Another option is the beta-3 adrenergic agonist mirabegron, which can be used in combination with an alpha-blocker to treat persistent urinary retention symptoms and is not recommended alone
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Mirabegron does not cause urinary retention and is therefore a particularly good treatment option for elderly patients who wish to avoid anticholinergic medication
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SUMMARY In general, if lower urinary tract symptoms are very bothersome and require medical treatment, alpha-blockers should be the first choice
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If the prostate is enlarged, consider adding a 5-alpha reductase inhibitor
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5-alpha reductase inhibitors can be used alone for enlarged prostate, but it takes a while to work
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Alternatively, tadalafil can be chosen first, which is a better choice for men who also suffer from erectile dysfunction
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For men with urinary frequency and urgency, anticholinergic drugs can be used alone or in combination with an alpha-blocker, or a beta-3 adrenergic agonist can be used in combination with an alpha-blocker
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Reference source: Managing the Lower Urinary Tract Symptoms of BPH: New Guidance - Medscape - Jan 20, 2022.