Management of BPH related symptoms- Canadian Updated guideline

The updated guideline that appeared in the Canadian Urological Association Journal relates to management of male lower urinary tract symptoms (MLUTS) secondary to benign prostatic hyperplasia (BPH). The new guideline is an updated version of 2010 Canadian Urological Association (CUA) BPH guideline.

These guidelines are directed toward the typical male patient over 50 years of age, presenting with LUTS and an enlarged benign prostate (BPE) and/or benign prostatic obstruction (BPO). It is recognized that men with LUTS associated with non-BPO causes may require more extensive diagnostic workup and different treatment considerations. The guideline includes both diagnostic and treatment issues.

1.Diagnostic Guidelines

The Key recommendations include:

1.1. Mandatory

In the initial evaluation of a man presenting with LUTS, the evaluation of symptom severity and bother is essential. A focused physical examination, including a digital rectal exam (DRE), is also mandatory. Urinalysis is required to rule out diagnoses other than BPH that may cause LUTS.

1.2. Recommended

Symptom inventory (should include bothering assessment): A formal symptom inventory (e.g., International Prostate Symptom Score [IPSS] or AUA Symptom Index [AUA-SI]) is recommended for an objective assessment of symptoms at initial contact

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PSA: Testing of prostate-specific antigen (PSA) should be offered to patients who have at least a 10-year life expectancy and for whom knowledge of the presence of prostate cancer would change management, as well as those for whom PSA measurement may change the management of their voiding symptoms (estimate for prostate volume).

1.3. Optional

In cases where the physician feels it is indicated or diagnostic uncertainty exists, it is reasonable to proceed with one or more of the following:

• – Serum creatinine


• – Urine cytology


• – Uroflowmetry


• – Post-void residual


• – Voiding diary (recommend frequency volume chart for men with suspected nocturnal polyuria)


• – Sexual function questionnaire

1.4. Not recommended

The following diagnostic modalities are not recommended in the routine initial evaluation of a typical patient with BPH-associated LUTS. These investigations may be required in patients with a definite indication, such as hematuria, uncertain diagnosis, DRE abnormalities, poor response to medical therapy, or for surgical planning.

• – Cytology


• – Cystoscopy


• – Urodynamics


• – Radiological evaluation of upper urinary tract


• – Prostate ultrasound


• – Prostate biopsy

2. Treatment guidelines

2.1. Principles of treatment

Therapeutic decision-making should be guided by the severity of the symptoms, the degree of bother, and patient preference.

Patients with mild symptoms (e.g., IPSS <7) should be counseled about a combination of lifestyle modification and watchful waiting.

Treatment options for patients with bothersome moderate (e.g., IPSS 8–18) and severe (e.g., IPSS 19–35) symptoms of BPH include watchful waiting/lifestyle modification, as well as medical, minimally invasive, or surgical therapies.

A variety of lifestyle changes may be suggested for patients with non-bothersome symptoms. These can include the following:

• – Fluid restriction, particularly prior to bedtime


• – Avoidance of caffeinated beverages, alcohol, and spicy foods


• – Avoidance/monitoring of some drugs (e.g., diuretics, decongestants, antihistamines, antidepressants)


• – Timed or organized voiding (bladder retraining)


• – Pelvic floor exercises


• – Avoidance or treatment of constipation

2.2. Post-treatment follow-up

Watchful waiting: Patients on watchful waiting should have periodic physician-monitored visits.

Medical therapy: Patients started on medical therapy should have followup visit(s) to assess for efficacy and safety (side effects of medications).

Surgical therapy: Patients after prostate surgery should be reviewed 4–6 weeks after catheter removal to evaluate treatment response (with symptom assessment [e.g., IPSS], and if indicated, uroflowmetry, and post-void residual [PVR] volume) and adverse events 2.3. Medical therapy.

2.3 Medical Therapy: The committee recommended few changes in the recommendations for the primary medical management of BPH and MLUTS with alpha-blockers and/or 5-alpha-reductase inhibitors (5ARIs) since 2010

2.3.1. Alpha-blockers

The guidelines recommend alpha-blockers as an excellent first-line therapeutic option for men with symptomatic bother who desire treatment (strong recommendation based on high-quality evidence).

2.3.2. 5ARIs

The guidelines recommend 5ARIs (dutasteride and finasteride) as an appropriate and effective treatment for patients with LUTS associated with demonstrable prostatic enlargement (strong recommendation based on high-quality evidence).

2.3.3. Combination therapy (alpha-blocker and 5ARI)

The guidelines recommend that the combination of an alpha-adrenergic receptor blocker and a 5ARI as an appropriate and effective treatment strategy for patients with symptomatic LUTS associated with prostatic enlargement (> 30 or 35 cc) (strong recommendation based on high-quality evidence). The guidelines also 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 based on moderate-quality evidence).

2.3.4. Antimuscarinic and beta-3 agonist medications

The guidelines suggest that antimuscarinics or beta-3 agonists may be useful therapies in MLUTS/BPH with caution in those with significant BOO and/or PVR (conditional recommendation based on low-quality evidence). The new guidelines also suggest that that alpha-blocker combination with antimuscarinics or beta-3 agonists may be useful therapies in MLUTS/BPH in some men (failure of alpha-blocker monotherapy) with both voiding and storage symptoms (conditional recommendation based on low-quality evidence).

2.3.5. Phosphodiesterase inhibitors

The guidelines recommend long-acting PDE5Is as therapy for men with MLUTS/BPH, particularly men with both MLUTS and erectile dysfunction (strong recommendation based on high-quality evidence).

2.3.6. Desmopressin

The guidelines recommend desmopressin as a therapeutic option in men with MLUTS/BPH with nocturia as a result of nocturnal polyuria (conditional recommendation based on moderate-quality evidence).

2.3.7. Phytotherapies

The updated guidelines do not recommend phytotherapies as standard treatment for MLUTS/BPH (moderate recommendation based on high-quality evidence).

2.4. Surgical therapy

2.4.1. M-TURP

The authors recommend M-TURP as a standard first-line surgical therapy for men with moderate to severe MLUTS/BPH with a prostate volume of 30–80 cc (strong recommendation based on high-to moderate-quality evidence).

The guidelines recommend B-TURP as a standard first-line surgical therapy for men with moderate to severe MLUTS/BPS with a prostate volume of 30–80 cc (strong recommendation based on moderate-to high-quality evidence).

The guidelines also suggest BPKVP as an alternative first-line surgical therapy for men with moderate to severe MLUTS/BPH and prostate volume <60 cc (conditional recommendation based on moderate-quality evidence).

2.4.2. Open simple prostatectomy (OSP)

The guidelines recommend OSP as a first-line surgical therapy for men with moderate to severe MLUTS/BPS and enlarged prostate volume >80 ccs (strong recommendation based on moderate-to high-quality evidence).

2.4.3. Laser prostatectomy

Holmium laser enucleation of the prostate (HoLEP)

The guidelines recommend HoLEP as an alternative to TURP or OSP in men with moderate to severe LUTS if performed by a HoLEP-trained surgeon (strong recommendation based on high-quality evidence). Moreover PVP as an alternative to TURP in men with moderate to severe LUTS (strong recommendation based on high-quality evidence). We suggest Greenlight PVP therapy as an alternative surgical approach in men on anticoagulation or with a high cardiovascular risk (conditional recommendation based on moderate-quality evidence) is recommended.

2.4.4. Transurethral incision of the prostate (TUIP)

The authors recommend TUIP to treat moderate to severe LUTS in men with prostate volume <30 ccs without a middle lobe (strong recommendation based on moderate-to high-quality evidence).

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The guidelines recommend that iTIND should not be offered at this time for the treatment of LUTS due to BPH (conditional recommendation based on very low-quality evidence). Moreover, Prostatic artery embolization (PAE) should not be offered at this time for the treatment of LUTS due to BPH (conditional recommendation based on moderate-quality evidence).

2.5. Special Situations

The guidelines suggest that selected, well-informed patients with symptomatic prostatic enlargement in the absence of significant bother may be offered a 5ARI to prevent progression of the disease (conditional recommendation based on moderate-quality evidence). men with AUR secondary to BPH may be offered alpha-blocker therapy during the period of catheterization (conditional recommendation based on moderate-quality evidence).

The guidelines recommend case-to-case patient-specific informed discussion and close PSA follow-up, as indicated in men on 5ARI therapy treatment for BPH (moderate recommendation based on high-quality evidence).

MLUTS secondary to BPH remains one of the most common age-related disorders afflicting men. The information offered in this guideline document, based on consensus evaluation of the best available evidence, will help urologists as they strive to provide state-of-the-art care to their patients.

For further reference log on to 10.5489/cuaj.5616