madman
Super Moderator
UPDATE – Canadian Urological Association guideline: Male lower urinary tract symptoms/ benign prostatic hyperplasia (2022)
Dean Elterman, Mélanie Aubé-Peterkin, Howard Evans, Hazem Elmansy, Malek Meskawi, Kevin C. Zorn, Naeem Bhojani
Introduction
The current document summarizes the state-of-the-art knowledge as it relates to the management of male lower urinary tract symptoms (MLUTS) secondary to benign prostatic hyperplasia (BPH) by updating the 2018 Canadian Urological Association (CUA) BPH guideline.1 The process continues to highlight the essential diagnostic and therapeutic information in a Canadian context. The information included in this document includes that reviewed for the 2010 guideline and further information obtained from an updated MEDLINE search of the English language literature (search terms included BPH, alpha-blockers, 5-alpha reductase inhibitor, anti-cholinergic, beta3 agonist, phosphodiesterase type 5 inhibitor [PDE5I], transurethral resection of the prostate [TURP], monopolar, bipolar, open simple prostatectomy, enucleation, GreenLight, photoselective vaporization of the prostate [PVP], Aquablation, Rezum, UroLift, temporarily implanted nitinol device [iTiND]), as well as a review of the most recent American Urological Association (AUA)2 and European Association of Urology (EAU) guidelines.3 References include those of historical importance, but management recommendations are based on literature published between 2000 and 2021. When information and data are available from multiple sources, the most relevant (usually most recent) article is cited based on committee opinion. These guidelines are directed toward the typical male patient over 50 years of age presenting with LUTS and benign prostatic enlargement (BPE) and/or benign prostatic obstruction (BPO). It is recognized that men with LUTS are associated with causes other than BPO and may require more extensive diagnostic workup and different treatment considerations. We acknowledge that not all patients identify as male. These guidelines should also be applicable to non-binary people, transwomen, and any patients who may have anatomical features of a cis-male genitourinary tract, such as the prostate. It is our intent to make these guidelines inclusive to all persons experiencing LUTS or an enlarged prostate.
In this document, we will address both diagnostic and treatment issues. Diagnostic guidelines are described in the following terms as: mandatory, recommended, optional, or not recommended. The recommendations for diagnostic guidelines and principles of treatment were developed on the basis of clinical principles (widely agreed upon by Canadian urologists) and/or expert opinion (consensus of committee and reviewers). The grade of recommendation will not be offered for diagnostic recommendations. Guidelines for treatment are described using the GRADE approach4 for summarizing the evidence and making recommendations.
1. Diagnostic guidelines
1.1. Mandatory
1.2. Recommended
-Symptom inventory (should include bother assessment)
-Prostate-specific antigen
1.3. Optional
1.4. Not recommended
1.5. Further diagnostic considerations for surgery
-Indications for surgery
-Preoperative testing
2. Treatment guidelines
2.1 Principles of treatment
2.2. Post-treatment followup
-Watchful waiting
-Medical therapy
-Surgical therapy
2.3 Medical therapy
2.3.1. Alpha-blockers
We recommend alpha-blockers as an excellent first-line therapeutic option for men with symptomatic bother due to BPH who desire treatment (strong recommendation, evidence level A).
2.3.2. 5-ARIs
We recommend 5-ARIs (dutasteride and finasteride) as an appropriate and effective treatment for patients with LUTS associated with a demonstrable prostatic enlargement (strong recommendation, evidence level A)
2.3.3. Combination therapy (alpha-blocker and 5-ARI)
We recommend the combination of an alpha-adrenergic receptor blocker and a 5-ARI as an appropriate and effective treatment strategy for patients with symptomatic LUTS associated with a prostatic enlargement (>30 cc) (strong recommendation, evidence level B)
It may be appropriate to consider discontinuing the alpha-blockers in patients successfully managed with combination therapy after 6–9 months of combination therapy.32,33
We suggest that patients successfully treated with combination therapy may be given the option of discontinuing the alpha-blocker. If symptoms recur, the alpha-blocker should be restarted (conditional recommendation, evidence level B).
2.3.4. Antimuscarinic and beta-3 agonist medications
We suggest that antimuscarinics or beta-3 agonists may be useful in predominately storage symptoms and BPH, and used with caution in those with significant BOO and/or an elevated PVR (conditional recommendation, evidence level C).
2.3.5. Antimuscarinic or beta-3 agonists in combination with alpha-blockers
We suggest that an alpha-blocker combined with an antimuscarinic or beta-3 agonist may be useful to treat LUTS/ BPH in men with both voiding and storage symptoms and failure of alpha-blocker monotherapy (conditional recommendation, evidence level B).
2.3.6. Phosphodiesterase inhibitors
We recommend long-acting PDE5Is as monotherapy for men with LUTS/BPH, particularly in men with both LUTS and erectile dysfunction (strong recommendation, evidence level B).
2.3.7. Desmopressin
We recommend desmopressin as a therapeutic option in men with LUTS/BPH with nocturia as result of NP (conditional recommendation, evidence level B).
2.3.8. Phytotherapies
We do not recommend phytotherapies as standard treatment for MLUTS/BPH (strong recommendation, evidence level B).
2.4. Surgical therapy
2.4.1. TURP
Monopolar TURP
We recommend M-TURP as a standard first-line surgical therapy for men with moderate-to-severe LUTS/BPH with a prostate volume of 30–80 cc (strong recommendation, evidence level A).
Bipolar TURP (including bipolar plasma kinetic vaporization)
We recommend B-TURP as a standard first-line surgical therapy for men with moderate-to-severe LUTS/BPS with a prostate volume of 30–80 cc (strong recommendation, evidence level B).
2.4.2. Open simple prostatectomy
We recommend OSP as first-line surgical therapy when anatomic endoscopic enucleation of the prostate (AEEP) (see below) is unavailable for men with moderate-to-severe LUTS/BPS and enlarged prostate volume >80 cc (strong recommendation, evidence level A).
2.4.3. Minimally invasive simple prostatectomy
We recommend LSP or RASP as alternative surgical therapies for men with moderate-to-severe LUTS/BPS and enlarged prostate volume >80 cc in centers where there are surgeons with high-level expertise in robotics or laparoscopy (conditional recommendation, evidence level B).
2.4.4. AEEP
We recommend AEEP as an alternative to TURP or OSP in men with moderate-to-severe LUTS and any size prostate >30 cc if performed by an AEEP-trained surgeon. AEEP can be safely performed in patients on AC/AP therapy (strong recommendation, evidence level A).
2.4.5. PVP
We recommend PVP as an alternative to M-TURP or B-TURP in men with moderate-to-severe LUTS (strong recommendation based on high-quality evidence). We also suggest GreenLight PVP therapy as an alternative surgical approach in men on anticoagulation or with a high cardiovascular risk (conditional recommendation, evidence level B).
2.4.6. Transurethral incision of the prostate
We recommend TUIP to treat moderate-to-severe LUTS in men with prostate volume <30 cc without a middle lobe. Patients should be made aware of the high retreatment rate (strong recommendation, evidence level B).
2.4.7. Minimally invasive techniques
Transurethral microwave therapy
We suggest TUMT therapy as consideration for the treatment of carefully selected, well-informed men (conditional recommendation, evidence level C).
Prostatic stents
We suggest prostatic stents only as an alternative to catheterization in men unfit for surgery with a functional detrusor (conditional recommendation, evidence level C).
Prostatic urethral lift
We suggest that prostatic urethral lift (UroLift) may be considered as an alternative treatment for men with LUTS interested in preserving ejaculatory function with prostates <80 cc. The prostatic urethral lift can also be offered to patients with a small-to-moderate median lobe and bothersome LUTS. Patients (with or without a median lobe) should be made aware of the higher retreatment rate at five years (conditional recommendation, evidence level C).
Convective water vapor energy ablation
We suggest that the Rezum system of convective water vapor energy ablation may be considered an alternative treatment for men with LUTS interested in preserving ejaculatory function with prostates <80 cc, including those with a median lobe (conditional recommendation, evidence level C).
Image-guided robotic waterjet ablation
We suggest that Aquablation be offered to men with LUTS interested in preserving ejaculatory function with prostates <150 cc, with or without a middle lobe (conditional recommendation, evidence level C).
Temporary implantable nitinol device
We recommend that iTind may be offered to men with LUTS interested in preserving ejaculatory function, with prostates 30-80 cc. Patients should be made aware of the higher retreatment rate at 3 years (conditional recommendation, evidence level C).
Prostatic artery embolization
At centers with urological and radiological collaboration and technical expertise, highly selected, well-informed patients may be offered PAE if they wish to consider an alternative treatment option. Patients should be informed of the lack of long-term durability (conditional recommendation, evidence level C).
Algorithms summarizing the management of a patient with MLUTS/BPH are summarized in Figures 2, and 3.
2.5. Special situations
AUR
We suggest that men with AUR secondary to BPH may be offered alpha-blocker therapy during the period of catheterization (conditional recommendation, evidence level B).
Detrusor underactivity
We have no evidence-based specific recommendation for the management of DU.
BPH-related bleeding
We suggest that a trial with a 5-ARI is appropriate in men with BPH-related hematuria (conditional recommendation, evidence level C).
BPH patients with prostate cancer concern
We recommend case-to-case, patient-specific informed discussion and close PSA follow-up, as indicated, in men on 5-ARI therapy treatment for BPH (conditional recommendation, evidence level B).
Summary
MLUTS secondary to BPH remains one of the most common age-related disorders afflicting men. As the aging of the Canadian population continues, more men will be seeking advice and looking for guidance from their healthcare providers on the management of their symptoms. The information offered in this guideline document, based on a consensus evaluation of the best available evidence, will aid Canadian urologists as they strive to provide state-of-the-art care to their patients.
Dean Elterman, Mélanie Aubé-Peterkin, Howard Evans, Hazem Elmansy, Malek Meskawi, Kevin C. Zorn, Naeem Bhojani
Introduction
The current document summarizes the state-of-the-art knowledge as it relates to the management of male lower urinary tract symptoms (MLUTS) secondary to benign prostatic hyperplasia (BPH) by updating the 2018 Canadian Urological Association (CUA) BPH guideline.1 The process continues to highlight the essential diagnostic and therapeutic information in a Canadian context. The information included in this document includes that reviewed for the 2010 guideline and further information obtained from an updated MEDLINE search of the English language literature (search terms included BPH, alpha-blockers, 5-alpha reductase inhibitor, anti-cholinergic, beta3 agonist, phosphodiesterase type 5 inhibitor [PDE5I], transurethral resection of the prostate [TURP], monopolar, bipolar, open simple prostatectomy, enucleation, GreenLight, photoselective vaporization of the prostate [PVP], Aquablation, Rezum, UroLift, temporarily implanted nitinol device [iTiND]), as well as a review of the most recent American Urological Association (AUA)2 and European Association of Urology (EAU) guidelines.3 References include those of historical importance, but management recommendations are based on literature published between 2000 and 2021. When information and data are available from multiple sources, the most relevant (usually most recent) article is cited based on committee opinion. These guidelines are directed toward the typical male patient over 50 years of age presenting with LUTS and benign prostatic enlargement (BPE) and/or benign prostatic obstruction (BPO). It is recognized that men with LUTS are associated with causes other than BPO and may require more extensive diagnostic workup and different treatment considerations. We acknowledge that not all patients identify as male. These guidelines should also be applicable to non-binary people, transwomen, and any patients who may have anatomical features of a cis-male genitourinary tract, such as the prostate. It is our intent to make these guidelines inclusive to all persons experiencing LUTS or an enlarged prostate.
In this document, we will address both diagnostic and treatment issues. Diagnostic guidelines are described in the following terms as: mandatory, recommended, optional, or not recommended. The recommendations for diagnostic guidelines and principles of treatment were developed on the basis of clinical principles (widely agreed upon by Canadian urologists) and/or expert opinion (consensus of committee and reviewers). The grade of recommendation will not be offered for diagnostic recommendations. Guidelines for treatment are described using the GRADE approach4 for summarizing the evidence and making recommendations.
1. Diagnostic guidelines
1.1. Mandatory
1.2. Recommended
-Symptom inventory (should include bother assessment)
-Prostate-specific antigen
1.3. Optional
1.4. Not recommended
1.5. Further diagnostic considerations for surgery
-Indications for surgery
-Preoperative testing
2. Treatment guidelines
2.1 Principles of treatment
2.2. Post-treatment followup
-Watchful waiting
-Medical therapy
-Surgical therapy
2.3 Medical therapy
2.3.1. Alpha-blockers
We recommend alpha-blockers as an excellent first-line therapeutic option for men with symptomatic bother due to BPH who desire treatment (strong recommendation, evidence level A).
2.3.2. 5-ARIs
We recommend 5-ARIs (dutasteride and finasteride) as an appropriate and effective treatment for patients with LUTS associated with a demonstrable prostatic enlargement (strong recommendation, evidence level A)
2.3.3. Combination therapy (alpha-blocker and 5-ARI)
We recommend the combination of an alpha-adrenergic receptor blocker and a 5-ARI as an appropriate and effective treatment strategy for patients with symptomatic LUTS associated with a prostatic enlargement (>30 cc) (strong recommendation, evidence level B)
It may be appropriate to consider discontinuing the alpha-blockers in patients successfully managed with combination therapy after 6–9 months of combination therapy.32,33
We suggest that patients successfully treated with combination therapy may be given the option of discontinuing the alpha-blocker. If symptoms recur, the alpha-blocker should be restarted (conditional recommendation, evidence level B).
2.3.4. Antimuscarinic and beta-3 agonist medications
We suggest that antimuscarinics or beta-3 agonists may be useful in predominately storage symptoms and BPH, and used with caution in those with significant BOO and/or an elevated PVR (conditional recommendation, evidence level C).
2.3.5. Antimuscarinic or beta-3 agonists in combination with alpha-blockers
We suggest that an alpha-blocker combined with an antimuscarinic or beta-3 agonist may be useful to treat LUTS/ BPH in men with both voiding and storage symptoms and failure of alpha-blocker monotherapy (conditional recommendation, evidence level B).
2.3.6. Phosphodiesterase inhibitors
We recommend long-acting PDE5Is as monotherapy for men with LUTS/BPH, particularly in men with both LUTS and erectile dysfunction (strong recommendation, evidence level B).
2.3.7. Desmopressin
We recommend desmopressin as a therapeutic option in men with LUTS/BPH with nocturia as result of NP (conditional recommendation, evidence level B).
2.3.8. Phytotherapies
We do not recommend phytotherapies as standard treatment for MLUTS/BPH (strong recommendation, evidence level B).
2.4. Surgical therapy
2.4.1. TURP
Monopolar TURP
We recommend M-TURP as a standard first-line surgical therapy for men with moderate-to-severe LUTS/BPH with a prostate volume of 30–80 cc (strong recommendation, evidence level A).
Bipolar TURP (including bipolar plasma kinetic vaporization)
We recommend B-TURP as a standard first-line surgical therapy for men with moderate-to-severe LUTS/BPS with a prostate volume of 30–80 cc (strong recommendation, evidence level B).
2.4.2. Open simple prostatectomy
We recommend OSP as first-line surgical therapy when anatomic endoscopic enucleation of the prostate (AEEP) (see below) is unavailable for men with moderate-to-severe LUTS/BPS and enlarged prostate volume >80 cc (strong recommendation, evidence level A).
2.4.3. Minimally invasive simple prostatectomy
We recommend LSP or RASP as alternative surgical therapies for men with moderate-to-severe LUTS/BPS and enlarged prostate volume >80 cc in centers where there are surgeons with high-level expertise in robotics or laparoscopy (conditional recommendation, evidence level B).
2.4.4. AEEP
We recommend AEEP as an alternative to TURP or OSP in men with moderate-to-severe LUTS and any size prostate >30 cc if performed by an AEEP-trained surgeon. AEEP can be safely performed in patients on AC/AP therapy (strong recommendation, evidence level A).
2.4.5. PVP
We recommend PVP as an alternative to M-TURP or B-TURP in men with moderate-to-severe LUTS (strong recommendation based on high-quality evidence). We also suggest GreenLight PVP therapy as an alternative surgical approach in men on anticoagulation or with a high cardiovascular risk (conditional recommendation, evidence level B).
2.4.6. Transurethral incision of the prostate
We recommend TUIP to treat moderate-to-severe LUTS in men with prostate volume <30 cc without a middle lobe. Patients should be made aware of the high retreatment rate (strong recommendation, evidence level B).
2.4.7. Minimally invasive techniques
Transurethral microwave therapy
We suggest TUMT therapy as consideration for the treatment of carefully selected, well-informed men (conditional recommendation, evidence level C).
Prostatic stents
We suggest prostatic stents only as an alternative to catheterization in men unfit for surgery with a functional detrusor (conditional recommendation, evidence level C).
Prostatic urethral lift
We suggest that prostatic urethral lift (UroLift) may be considered as an alternative treatment for men with LUTS interested in preserving ejaculatory function with prostates <80 cc. The prostatic urethral lift can also be offered to patients with a small-to-moderate median lobe and bothersome LUTS. Patients (with or without a median lobe) should be made aware of the higher retreatment rate at five years (conditional recommendation, evidence level C).
Convective water vapor energy ablation
We suggest that the Rezum system of convective water vapor energy ablation may be considered an alternative treatment for men with LUTS interested in preserving ejaculatory function with prostates <80 cc, including those with a median lobe (conditional recommendation, evidence level C).
Image-guided robotic waterjet ablation
We suggest that Aquablation be offered to men with LUTS interested in preserving ejaculatory function with prostates <150 cc, with or without a middle lobe (conditional recommendation, evidence level C).
Temporary implantable nitinol device
We recommend that iTind may be offered to men with LUTS interested in preserving ejaculatory function, with prostates 30-80 cc. Patients should be made aware of the higher retreatment rate at 3 years (conditional recommendation, evidence level C).
Prostatic artery embolization
At centers with urological and radiological collaboration and technical expertise, highly selected, well-informed patients may be offered PAE if they wish to consider an alternative treatment option. Patients should be informed of the lack of long-term durability (conditional recommendation, evidence level C).
Algorithms summarizing the management of a patient with MLUTS/BPH are summarized in Figures 2, and 3.
2.5. Special situations
AUR
We suggest that men with AUR secondary to BPH may be offered alpha-blocker therapy during the period of catheterization (conditional recommendation, evidence level B).
Detrusor underactivity
We have no evidence-based specific recommendation for the management of DU.
BPH-related bleeding
We suggest that a trial with a 5-ARI is appropriate in men with BPH-related hematuria (conditional recommendation, evidence level C).
BPH patients with prostate cancer concern
We recommend case-to-case, patient-specific informed discussion and close PSA follow-up, as indicated, in men on 5-ARI therapy treatment for BPH (conditional recommendation, evidence level B).
Summary
MLUTS secondary to BPH remains one of the most common age-related disorders afflicting men. As the aging of the Canadian population continues, more men will be seeking advice and looking for guidance from their healthcare providers on the management of their symptoms. The information offered in this guideline document, based on a consensus evaluation of the best available evidence, will aid Canadian urologists as they strive to provide state-of-the-art care to their patients.
