New BPH guidelines address new drugs, watchful waiting, and when to try surgery

An updated clinical guideline on treatment of benign prostatic hyperplasia (BPH) from the American Urological Association (AUA) includes a detailed diagnostic algorithm to guide physicians in diagnosing and treating lower urinary tract symptoms (LUTS) secondary to BPH, as well as in-depth information on management of basic and complicated cases.

The full guideline, which updates the association's 2003 version, is online. The 2010 edition adds recommendations for the use of anti-cholinergic drugs and laser therapies. Additionally, the index patient age has been lowered to 45 years from 50 years, to better guide physicians in treating younger men who may be experiencing lower urinary symptoms.

Clinicians should not underestimate the effects of LUTS on patients' quality of life, according to the new guidelines. Traditionally, the primary goal has been to relieve bothersome LUTS. More recently, treatment has focused on changing disease progression and preventing complications. A variety of drug classes can be used, including alpha-adrenergic antagonists, 5-alpha-reductase inhibitors, anticholinergics and phytotherapeutics.

Physicians treating men with suspected cases of LUTS should obtain a relevant medical history, assess symptoms using the AUA Symptom Index and conduct a full physical examination, including a digital rectal exam. Laboratory tests should include a prostate-specific antigen test and a urinalysis to exclude infection or other causes for LUTS. Frequency and volume charts may also be useful in providing a diagnosis.

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 symptoms should be managed using a strategy of watchful waiting. It is also an appropriate option for men with moderate to severe symptoms who have not yet developed complications of LUTS and bladder output obstruction, such as renal insufficiency, urinary retention or recurrent infection. The guidelines also address at what stage to consider surgical options, as well as several new modalities.

Physicians should question patients about any planned cataract surgery prior to starting an alpha-blocker regimen, as men planning cataract surgery should avoid these drugs until after surgery has been completed. The risk of intraoperative floppy iris syndrome was substantial among men taking tamsulosin, ranging from about 43% to 90% in 10 retrospective and prospective studies. Men already taking the drugs should inform their ophthalmologists of their alpha-blocker regimen prior to surgery, the guidelines said.