The recommendations that follow summarize the content of the guideline. Please refer to the original guideline document for more detailed recommendations. Each recommendation is rated based on the level of the evidence and the grades of recommendation. Definitions of the grades of the recommendations (A, B, C, Good Practice Points [GPP]) and level of the evidence (Level I-Level IV) are presented at the end of the "Major Recommendations" field.
Guidelines for Family Physicians
Identification and Evaluation
GPP - When a patient is above 50 years of age and presents with lower urinary tract symptoms, history-taking should include these three basic questions:
- Do you get up more than once at night to pass urine?
- Do you have to wait a long time to initiate urination and do you have a weak stream?
- Are you bothered by your urination pattern?
Other important signs and symptoms include:
- Blood in the urine (haematuria)
- Uncontrolled leakage of urine (incontinence). (GPP)
GPP - Conduct a clinical examination including:
- Digital rectal examination (DRE) to assess size and exclude cancer of the prostate (when the prostate is hard and/or irregular).
- Abdominal examination to exclude palpable bladder. (GPP)
C - Conduct a urine labstix test to detect haematuria, pyuria, and glycosuria. (Grade C, Level IV)
C - Offer the option of serum prostate specific antigen (PSA) test. (Grade C, Level IV)
B - Ultrasound examination of the urinary system may be considered. The purposes are to estimate residual urine and to detect hydronephrosis of the kidneys. (Grade B, Level III)
Management
B - In a patient with benign prostatic hyperplasia (BPH) without significant obstruction and without bothersome symptoms (Stage I): watchful waiting is an acceptable option. (Grade B, Level III)
GPP - Family physicians who are confident of evaluation of lower urinary tract symptoms (LUTS)/BPH can initiate treatment with medical therapy if the patient is bothered by his symptoms, has no significant residual urine, and cancer of the prostate has been excluded. (GPP)
A - Alpha-adrenergic blockers are recommended as first-line medical therapy for patients with bothersome symptoms. They have been shown to be effective in improving symptoms. (Grade A, Level Ia)
A - 5alpha-reductase inhibitors can be considered an acceptable first-line treatment for patients with large glands. (Grade A, Level Ia)
A - 5alpha-reductase inhibitors should be taken for at least 3 to 6 months to be effective. (Grade A, Level Ia)
A - In the event that PSA is more than 2.0 micrograms/L, a urological assessment is recommended. (Grade A, Level Ib)
Indications for Referral to a Urologist
C - Consider referring the patient to a urologist when he presents with or has:
- Retention of urine
- Palpable bladder and/or high residual urine
- Incontinence
- Haematuria
- Proven urinary tract infection (UTI)
- Persistent bothersome symptoms
- Bladder stones
- Hard and/or irregular prostate
- PSA > 4 micrograms/L (> 2 micrograms/L if on 5alpha-reductase inhibitors) (Grade C, Level IV)
Guidelines for Urologists
Recommended Evaluation
GPP - Conduct a clinical examination including:
- Digital rectal examination to assess size and exclude cancer of the prostate (when the prostate is hard and/or irregular)
- Abdominal examination to exclude palpable bladder (GPP)
C - Conduct a urine labstix test to detect haematuria, pyuria, and glycosuria. (Grade C, Level IV)
C - Offer the option of serum PSA test. (Grade C, Level IV)
C - Consider a voiding diary (frequency-volume chart) when nocturia is the dominant symptom. (Grade C, Level IV)
B - Detect possible hydronephrosis with ultrasound of kidneys. This is more sensitive than measuring serum creatinine levels to detect back pressure effect of obstruction. (Grade B, Level III)
B - Ascertain the post-void residual urine with transabdominal ultrasound examination. (Grade B, Level III)
B - Assess the size and the degree of intravesical prostatic protrusion (IPP) with transabdominal ultrasound scan. This information helps to predict the natural history of the disease. (Grade B, Level III)
B - Assess severity and degree of bother of the patient's symptoms using the International Prostatic Symptom Score (I-PSS) and the Quality Of Life (QOL) index. (Grade B, Level III)
B - Use uroflowmetry to determine the degree of urine flow impairment. (Grade B, Level III)
Optional Evaluation
These investigations may be indicated for selected patients.
B - Transrectal Ultrasound (TRUS) with biopsy is recommended for patients with:
- Suspicious digital rectal examination findings
- Elevated PSA (Grade B, Level III)
C - Urodynamic Studies (UDS) are recommended:
- When it is not certain whether outlet obstruction or neuropathic bladder is the cause of voiding dysfunction
- For patients with bothersome symptoms but no clinical or ultrasound evidence of obstruction (no IPP)
- For patients with previous surgery (Grade C, Level IV)
C - Flexible cystoscopy is recommended for patients with:
- Previous lower urinary tract surgery
- Obstruction suspected to be due to non-BPH causes (significant residual urine with small volume prostate and low IPP)
- Hematuria (Grade C, Level IV)
Management
The guidelines recognize the different philosophies of treatment held by practitioners. The following is a possible framework for selecting treatment. Patient's age, general medical conditions, and preferences should be taken into consideration.
Significant obstruction is defined by persistently high residual urine (more than 100 mL) and low flow rate of less than 10 mL/s. This is generally associated with prostate volume more than 40 gm and significant IPP (more than 1 cm).
B - In a patient with BPH without significant obstruction and without bothersome symptoms (Stage I), watchful waiting is an acceptable option. (Grade B, Level III)
B - In a patient with BPH with significant obstruction with or without bothersome symptoms (Stage III), surgery can be considered, if the patient is fit. (Grade B, Level III)
B - In a patient with BPH without significant obstruction but who has bothersome symptoms (Stage II), after discussing with the patient, medical treatment with alpha-adrenergic blockers may be used for symptomatic relief, and 5alpha-reductase inhibitors for a gland of more than 40 gm. (Grade B, Level III)
C - The following conditions indicate complicated BPH (Stage IV) and are definite indications for surgery:
- Repeated acute retention of urine
- Chronic retention of urine
- Bladder stones
- Recurrent urinary infections
- Recurrent or persistent gross hematuria (Grade C, Level IV)
B - Prostatic stenting is indicated in elderly and frail patients at high risk for surgery. (Grade B, Level III)
A - Transurethral microwave thermotherapy (TUMT) is not routinely recommended as a less invasive treatment of BPH. (Grade A, Level Ib)
A - Interstitial laser coagulation is not routinely recommended for treatment of BPH. (Grade A, Level Ib)
Definitions:
Grades of Recommendations
Grade A (evidence levels Ia, Ib): Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation
Grade B (evidence levels IIa, IIb, III): Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation
Grade C (evidence level IV): Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates absence of directly applicable clinical studies of good quality.
GPP (good practice points): Recommended best practice based on the clinical experience of the guideline development group
Levels of Evidence
Level Ia: Evidence obtained from meta-analysis of randomised controlled trials
Level Ib: Evidence obtained from at least one randomised controlled trial
Level IIa: Evidence obtained from at least one well-designed controlled study without randomisation
Level IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
Level III: Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative studies, correlation studies, and case studies
Level IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities
