AUA GUIDELINE ON MANAGEMENT OF BENIGN PROSTATIC
HYPERPLASIA (2003).CHAPTER 1:DIAGNOSIS AND TREATMENT
RECOMMENDATIONS
AUA PRACTICE GUIDELINES COMMITTEE
Benign prostatic hyperplasia (BPH),one of the most com-mon dias of aging men,1can be associated with bother-some lower urinary tract symptoms (LUTS)that affect qual-ity of life by interfering with normal daily activities and sleep patterns.The prevalence of histopathologic BPH is age de-pendent,with initial development usually after 40years of age.2By 60years of age,its prevalence is greater than 50%and by age 85it is as high as 90%.Similar to that of histologic evidence,the prevalence of bothersome symptoms also in-creas with age.Approximately half of all men who have a histologic diagnosis have moderate to vere LUTS.1Becau long-term data from population-bad studies have only recently become available,the risks of developing complications and morbidities from untreated BPH are un-clear.For example,despite recent evidence,there is still uncertainty regarding the likelihood that a patient with a specific symptom complex will develop complete urinary re-tention within a particular time frame.Nonetheless,BPH associated mortality is ra
re in the United States,and rious complications are uncommon.In contrast,LUTS are bother-some to many patients,and the amount of bother may differ greatly among individuals with the same degree of symptom
frequency and verity.3Since the impact of LUTS on the
patient’s quality of life is highly variable and not directly related to any measurable physiological factors,the patient’s perception of the verity of the condition,as well as the degree to which it interferes with his lifestyle or caus embarrassment,should be the primary consideration in choosing therapy.4,5In the past decade,there have been significant changes in the available treatment options for BPH.New forms of med-ical and minimally invasive treatments have been approved by the United States Food and Drug Administration (FDA)while other therapies have become obsolete.This update of the 1994AHCPR benign prostatic hyperplasia clinical prac-tice guideline produced by the Agency for Health Care Policy and Rearch of the United States Department of Health and Human Services (AHCPR;now known as the Agency for
Healthcare Rearch and Quality)was developed by a panel of experts (hereafter the Panel)chon by the American Urological Association (AUA)Practice Guidelines Commit-tee.Using an evidence-ba
d approach,the multidisciplinary Panel focud on providing scientifically bad information on currently available BPH treatment modalities.Becau the Panel strongly believes that the patient should play a central role in determining his need for treatment,it t out
to address the issue of whether or not there was sufficient evidence for outcomes (both benefits and risks)to be esti-mated.Thus,this guideline is intended to provide scientifi-cally bad information on treatment outcomes so that phy-sicians can assist their patients in making appropriate treatment decisions.DEFINITIONS AND TERMINOLOGY Benign prostatic hyperplasia is defined histologically as a dia process characterized by stromal and epithelial cell hyperplasia beginning in the periurethral zone of the pros-tate.6,7The chief complaint of the patient with BPH is usu-ally bothersome LUTS typified by urinary frequency,ur-gency,nocturia,decread and intermittent force of stream and the nsation of incomplete bladder emptying.The rela-tionship between BPH and LUTS is complex,however,be-cau not all men with histological evidence of BPH will develop LUTS.In addition,LUTS are neither specific to nor exclusive of BPH;other conditions in the lower urinary tract and elwhere may be causative.Moreover,not all patients with BPH and LUTS will have prostate enlargement,and prostate enlargement may exist in the abnce of LUTS.The 4th International Consultation on BPH recommended the u of the general terminology LUTS or “LUTS suggestive o
f BPH”in place of the older term “prostatism”until a cau-and-effect BPH-symptom relationship has been established.8Recognizing the complexities of this nomenclature,the Panel decided that the term “BPH”would be ud in this document when referring to any symptomatic conditions characterized by bothersome LUTS attributed to histological hyperplasia or incread tone of the prostate.
METHODOLOGY
As in the development of the 1994AHCPR guideline,a systematic literature review was conducted bad on the results of a MEDLINE arch.The arch,which spanned the years from 1991through early 2000,was supplemented with additional references from Panel members and addi-tional data obtained from authors to explicate data previ-ously published.The Panel chairmen reviewed the arch results,and data were extracted to forms and entered into databas from which evidence tables were generated.After review by the Panel,some studies were excluded from addi-tional analysis becau of lack of relevance or quality prob-lems.
The Panel had two principal tasks:
●to
determine whether or not there was convincing scientific evidence that the benefits of a given treat-ment option (primarily symptom improvement)out-weighed the risks (adver events);and
●to
explicitly define the primary outcomes of the rec-ommended treatment options to assist patients and physicians in an informed decision-making process.The Panel also outlined recommendations for future clinical rearch priorities.
Data on efficacy and safety of the following BPH treat-ments were reviewed:watchful waiting,alpha-adrenergic blocker therapy,5alpha-reducta inhibitor therapy,trans-urethral microwave heat treatment,transurethral needle ab-
lation (TUNA ),interstitial lar therapy,stents,and vari-
ous forms of transurethral surgery and open surgery.In
addition,data on emerging transurethral heat-bad tech-
nologies and high-intensity focud ultrasound (HIFU)were examined.The published literature on phytotherapy was
承诺歌词also evaluated,although there were few randomized clinical
trials of suitable duration to allow comment.
Detailed analysis of study outcomes using a variety of meta-analytic techniques was performed,and outcomes ta-
This document is being reprinted as submitted without editorial
review.The complete main report is available at shop.auanet/timmsnet/products/guidelines/bph_management.cfm.0022-5347/03/1702-0530/0Vol.170,530–547,August 2003T HE J OURNAL OF U ROLOGY ®Printed in U.S.A.Copyright ©2003by A MERICAN U ROLOGICAL A SSOCIATION DOI:10.1097/01.ju.0000078083.38675.79530For Internal U Only
bles were created for Panel review.Treatment recommenda-tions were bad on the outcomes tables and tempered by the Panel’s expert opinion.Key evidence for some interven-tions became available after the outcomes analysis was com-plete.The Panel directly reviewed the data and agreed that the new information should be considered for inclusion in the guideline.Thus,evidence fr
om veral studies support rec-ommendations made by Panel connsus;however,the data are not prented as outcomes estimates.
Of note,FDA approval alone was not sufficient to justify a positive recommendation in this guideline.First,FDA ap-proval may be requested by a manufacturer for a non-BPH indication becau a specific BPH indication may be more complicated and expensive to attain.Second,FDA approval may precede the publication of key pivotal studies,preclud-ing Panel analysis.Third,FDA approval once given does not imply that the intervention is still currently recommended or even ,balloon dilation).Finally,the FDA may have approved a treatment that the Panel believes is not appropriate given the other available treatment options. This guideline was drafted,reviewed by the Panel,then examined by58peer reviewers,and finally approved by the Practice Guidelines Committee and the Board of Directors of the AUA.A full description of the methodology is prented in Chapter2and in the Methodologic Appendix of this guide-line(www.auanet).
As in the1994AHCPR guideline,the Panel generated recommendations bad on the strength of the evidence for both diagnostic and treatment modalities and the expected amount of variation in patient preferences for treatments.In some cas,recommendations were supported solely by the Pa
nel’s expert opinion and are designated as such in the text. For diagnostic tests,the Panel utilized the terms“recom-mended,”“optional,”and“not recommended”to indicate the desirability of specific diagnostics.Treatment recommenda-tions were graded according to three levels of flexibility.9,10 For treatments,the term“standard”is the least flexible of the three,a“guideline”is more flexible,and an“option”is the most flexible.Options can exist becau of insufficient evi-dence or becau patient preferences are divided.The grad-ing of diagnostic and treatment recommendations is detailed in chapter2(www.auanet.)
The1994AHCPR guideline defined an Index Patient(the specific type of patient to whom the recommendations ap-plied)in recognition of the differences in decision making that depend upon patient circumstances.Similarly,the diagnostic and treatment guidelines pertain only to men over the age of50without significant risk(as ascertained by history)of non-BPH caus of LUTS.Men with polyuria, underlying neurologic dia,or prior lower urinary tract dia and younger men with voiding dysfunction will re-quire more extensive evaluation.The important caus of voiding function are not specifically addresd in this guide-line.
DIAGNOSTIC EVALUATION OF BENIGN PROSTATIC
HYPERPLASIA
吃什么水果能变白Upon review of the diagnostic recommendations in the 1994AHCPR guideline,the Panel decided that an evidence-bad update was not necessary.The Panel unanimously agreed that the prior recommendations and decision diagram for diagnosis were still valid and reflective of“best practice”with five exceptions,which were derived from the Panel’s expert opinion:
●Serum prostate-specific antigen(PSA)meas-
urement is recommended in lect patients;
●Urine cytology is recommended as an option in
men with predominantly irritative symptoms;
●Other validated symptom asssment instru-
ments are supplementary to the AUA Symptom
Score;
●Serum creatinine measurement is no longer rec-
ommended on initial evaluation in the standard
patient;and
●Discussion of treatment options with the pa-
tient is recommended before pressure-flow test-
ing is performed.
The1994diagnostic guidelines,with italicized revisions,are revisited below using the previously referenced studies from that publication.
An algorithm(figure1.1)is provided as a framework for diagnosis and treatment and not as a rigid pathway that must be followed in all cas.Individual patients will prent for whom deviations from the policies are appropriate.In such circumstances,the clinician should exerci clinical judgment and act in the patient’s best interest.
Initial evaluation.Lower urinary tract pathologies in aging men produce similar,if not identical,symptoms.Therefore, the challenge in patients with LUTS is to establish that the symptoms
are due to BPH.Nonprostatic caus of symptoms can be excluded in a significant number of patients on the basis of a medical history,physical examination,and urinal-ysis.
Recommended:In the initial evaluation of all pa-tients prenting with LUTS suggestive of BPH:
●A medical history should be taken to identify
other caus of voiding dysfunction or comor-
bidities that may complicate treatment.
The medical history should focus on the urinary tract, previous surgical procedures,and general health issues,spe-cifically,medical conditions and symptoms that lead to blad-der dysfunction or excessive urine production(polyuria),
fam-
Benign prostatic hyperplasia(BPH)diagnosis and treatment
MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA531
For Internal U Only
ily history of prostate dia(BPH and cancer),and fitness for possible surgical procedures.Patient voiding diaries, where the frequency of micturition and urine volume is re-corded,may be helpful in lected patients,especially in tho with nocturia as the predominant symptom.
●A physical examination,including both a digital
rectal examination(DRE)and a focud neuro-
logic examination,should be performed.
The prence of locally advanced prostate cancer,which also can produce LUTS,should be excluded by DRE.Digital rectal exam tends to underestimate the true prostate size:if the prostate feels large b
y DRE,it usually also is found to be enlarged by ultrasound or other measurement tech-niques.11,12A focud neurologic examination should asss the patient’s general mental status,ambulatory status,lower extremity neuromuscular function,and anal sphincter tone.
●A urinalysis should be performed by dipstick
testing or microscopic examination of the di-
ment to screen for hematuria and urinary tract
infection(UTI).
Bladder cancer,carcinoma in situ of the bladder,UTIs, urethral strictures,distal urethral stones,and bladder stones can produce LUTS in aging men.Although hematuria or pyuria is not universally prent in the conditions,a normal urine examination makes the diagnos less like-ly.13–16
●Measurement of the rum prostate-specific an-
tigen(PSA)should be offered to the following
patients:1)tho with at least a10-year life ex-
pectancy and for whom knowledge of the pres-
ence of prostate cancer would change manage-
ment;or2)tho for whom the PSA measurement
may change the management of their voiding
symptoms.
Serum PSA is one predictor of the natural history of BPH—men with higher rum PSA levels have a higher risk of future growth of the prostate,symptom and flow rate dete-rioration,acute urinary retention,and BPH-related sur-gery.17–19This recommendation does not address the value of PSA screening in the testing of asymptomatic men in the general population.Rather,becau prostate cancer is one of the potential caus of LUTS in aging men,PSA(together with DRE)is a relatively nsitive way to exclude prostate cancer as a diagnosis.20–22Physician and patient concern, however,lies with the specificity of the test—approximately 25%of men with BPH have a rum PSA greater than4 ng/ml.Becau of the overlap between rum PSA values in men with BPH and tho with clinically localized prostate cancer,PSA velocity(PSAV),free/total PSA ratio,complexed PSA(cPSA),and PSA density(PSAD)measurements may help improve diagnostic specificity.23,24
The benefits and risks of PSA testing should be discusd with the patient.In most patients,a normal DRE should be sufficient to exclude locally advanced cancer as a cau of voiding dysfunction.Prostate-specific antigen testing is most appropriate for patients likely to have a natural life span greater than10years and in whom the known prence of prostate cancer would change management or for whom the PSA measurement may change the management of the pa-tient’s voiding symptoms.[This recommendation is bad on the Panel’s expert opinion.]
Optional:Urine cytology may be considered in men with a predominance of irritative symptoms,especially with a history of smoking or other risk factors,to aid in the diagnosis of bladder carcinoma in situ and bladder cancer.
Not recommended:The routine measurement of -rum creatinine levels is not indicated in the initial evaluation of men with LUTS condary to BPH. Baline renal insufficiency appears to be no more common in men with BPH than in men of the same age group in the general population.The Panel reviewed the experience in veral large BPH clinical trial databas that have more than10,000patient-years of follow-up.Renal insufficiency has been reported in well under1%of patients in the studies and is commonly condary to non-BPH , diabetic nephropathy).Moreover,in the MTOPS trial(Med-ical Therapy of Prostatic Symptoms),81out of4394(1.
8%) men screened for participation were excluded due to renal or hepatic impairment,defined as rum creatinineϾ2mg/dl or significant liver enzyme abnormalities,respectively.No in-formation is available regarding the number of patients who renal insufficiency was due to BPH versus other caus-es;thus,the number of men prenting with renal insuffi-ciency due to BPH is most likely also under1%.If urinalysis and/or history and physical examination suggest underlying renal dia or urinary retention,measurement of rum creatinine also may be necessary prior to the performance of renal imaging studies that require intravenous contrast. [The recommendations are bad on the Panel’s expert opinion.]
Symptom asssment.Most patients who ek treatment for BPH do so becau symptoms alter quality of life.Symp-tom quantification is therefore of major importance in deter-mining the verity of dia,in documenting the respon to therapy,and in detecting symptom progression in men managed by watchful waiting.The AUA Symptom Index (Appendix1-A)or the identical IPSS is recommended for symptom asssment in each patient prenting with BPH becau it is superior to an unstructured interview in quan-tifying symptom frequency and verity.Using ven ques-tions that relate to associated symptoms,1classification ranges from mild(0to7)to moderate(8to19)to vere(20 to35).25,26Some patients may require an explanation of the questions to adequately und
erstand their intent.Although validated for its clarity,test/retest reliability,internal con-sistency,and criteria strength,this tool is not a replacement for personal discussion of symptoms with the patient. Recommended:The AUA Symptom Index(identical to the ven symptom questions of the International Prostate Symptom Score[IPSS])should be ud as the symptom-scoring instrument in the initial asssment of each patient prenting with BPH.
Symptom score changes and the degree of each patient’s bother due to the symptoms should be the primary determi-nants of treatment respon or dia progression in the follow-up period.However,symptom scores alone do not de-lineate the morbidity of a prostate problem as perceived by the individual patient.An intervention may be more logical for a moderately symptomatic patient who finds his symp-toms bothersome than for a verely symptomatic patient who finds his symptoms tolerable.
Optional:Other validated asssment instruments addressing the frequency or verity of LUTS in men with BPH,bother due to symptoms,interference with daily activities,urinary continence,xual functioning and health-related general or dia-specific quality of life may be administered.
Examples of the instruments are the International Con-tinence Society male questionnaire27and t
he Danish Pros-tatic Symptom Score,28which measure symptom verity and frequency;the BPH Impact Index(Appendix1-B),3 which measures the impact of symptoms on activities of daily living and their level of interference;and the Dia Specific Quality of Life(QoL)question of the IPSS(Appendix1-A), which measures quality of life as it is impacted and impaired by BPH.Baline xual function,treatment choices,and/or impact of treatment is measured by xual function question-
MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA
532爱国童谣
For Internal U Only
中国互联网naires.[The recommendations are bad on Panel expert opinion.]
Optional diagnostic tests.Optional tests are tho that are not required but may aid in the decision-making process. When the initial evaluation suggests a nonprostatic cau for the patient’s symptoms or when the patient lects invasive therapy,the physician may consider additional diagnostic testing if the results of the test(s)are likely to change the patient’s management or more pr
ecily predict the benefits and risks of the lected treatment.The1994AHCPR guide-line suggested that the physician consider performing one or more“optional”diagnostic tests prior to offering treatment options to the patient.29In some cas,additional diagnostic tests may aid in the lection of an invasive treatment that is best for an individual ,identification of prostate middle lobe).The20015th International Consultation on BPH,co-sponsored by the World Health Organization,also deemed flow rate and post-void residual urine(PVR)volume to be optional tests for men who were considering therapy for bothersome LUTS.
Optional:Following the initial evaluation of the pa-tient,urinary flow-rate recording and measurement of post-void residual urine(PVR)may be appropriate. The tests usually are not necessary prior to the in-stitution of watchful waiting or medical therapy.How-ever,they may be helpful in patients with a complex medical ,neurologic or other dias known to affect bladder function or prior failure of BPH therapy)and in tho desiring invasive therapy. Urinary flow-rate recording(uroflowmetry),specifically Qmax,may predict the respon to surgery and,to a lesr degree,the natural history of the dia.Men with LUTS and normal Qmax are more likely to have a non-BPH-related cau of their symptoms.Nevertheless,the symptom re-spon to many therapies,specifically alpha blockers,is not dependent upon baline flow rate.Men with Qmax less t
han 10ml/c are more likely to have urodynamic obstruction and are therefore more likely to improve with surgery.Men with normal flow rates but significant urinary symptoms are more likely to have nonprostatic caus for tho symptoms requir-ing more extensive investigation.Urinary flow rate,though, predicts less well the respon to medical therapy or the failure of watchful waiting.Becau of test-retest variability and a lack of appropriately designed outcome studies,it is not feasible to establish a flow-rate“cut-point”for decision mak-ing.
Large PVR ,350ml)may indicate bladder dysfunction and predict a slightly less favorable respon to treatment.In addition,large PVRs may herald progression of dia.Still,residual urine is not a contraindication to watch-ful waiting or medical therapy.Becau of large test-retest variability and a lack of appropriately designed outcome stud-ies,it is not feasible to establish a PVR“cut-point”for decision making.The Panel considered the u of PVR measurements optional in men undergoing noninvasive therapy bad on the obrvation that the safety of noninvasive therapy has not been documented in patients with residual urine(200to300ml).In some studies,however,residual urine has predicted a high failure rate of watchful waiting.30Within the range of residual urine values from0to300ml,the PVR does not predict the respon to medical therapy.Although long-term,controlled data are lacking,many patients maint
爆字的笔顺ain fairly large amounts of residual urine without evidence of UTI,renal insufficiency,or bothersome symptoms.Therefore,no level of residual urine,in and of itlf,mandates invasive therapy.
INITIAL MANAGEMENT AND DISCUSSION OF TREATMENT
OPTIONS WITH THE PATIENTS
Management of patients with mild symptoms or moderate to vere symptoms without bother.From the initial evalua-tion,the physician should determine whether the patient has developed a rious complication of BPH that would direct treatment toward surgical options.Patients with only mild symptoms or moderate to vere symptoms that are not bothersome generally will not benefit from therapy becau the symptoms do not significantly impact quality of life.25,26,31In addition,the risks of medical therapy outweigh the benefits of symptom improvement in this group of men. Therefore,the Panel felt that the recommendation,from the 1994AHCPR guideline,was still appropriate with one mod-ification,which is the inclusion of men with“nonbothersome”symptoms in the“mild”category.Men who have moderate to vere symptom frequency and verity but are not bothered by their symptoms should not be considered for further diag-nostic tests or active treatment.
Standard:Patients with mild symptoms of BPH (AUA Symptom Score<7)and patients with moderate or vere symptoms(AUA Symptom Score>8)who are not bothered by their ,they do not in-terfere with the daily activities of living)should be managed using a strategy of watchful waiting. Management of patients with bothersome moderate to -vere symptoms.The degree to which BPH patients are both-ered by LUTS varies among individual patients with the same level of symptoms,although in general the level of bother and interference will increa with the level of symp-tom verity.32Although patients with mild symptoms or mild to vere symptoms that are not bothersome prefer watchful waiting,there is a wide range of preference in patients with bothersome moderate to vere symptoms.29 Therefore,the“best”treatment from the patient’s viewpoint may differ from that believed by the physician to be the most efficacious treatment.Patients may prefer less effective ther-apy if it also has less risk or cost.Treatment options—watchful waiting and medical,minimally invasive or surgical therapies—are defined in table1.1,and information on their harms and benefits is prented in the Simplified Outcomes Tables(Appendix1-C).
Option:Treatment options for patients with bother-some moderate to vere symptoms of BPH(AUA Symptom Score>8)include watchful waiting and the medical,minimally invasive,or surgical therapies de-fined in table1.1.
Guideline:Information on the benefits and harms of the BPH treatment options(including watchful wait-ing)should be explained to patients with moderate to vere symptoms(AUA Symptom Score>8)who are bothered enough to consider therapy.
At this point,the benefits and risks of all therapeutic interventions should be discusd with the patient using the Simplified Outcomes Tables prented in Appendix1-C.It is appropriate for patients with moderate symptoms and bother to choo watchful waiting if they feel that the benefits out-weigh the risks of an active therapy.Patients choosing med-ical therapies may be prescribed the most appropriate agent(s)at this time without additional testing.Patients choosing invasive therapies may benefit from additional op-tional diagnostic tests.
Optional diagnostic tests for patients who choo invasive therapy.Determining the relative significance of performing certain diagnostic tests prior to treatment initiation has been a complex task.In the BPH clinical trial tting,eligibility criteria usually exclude patients who diagnostic test meas-urements exceed certain limits.Thus,the ability of a diag-nostic test to predict natural history and outcomes in pa-tients who measurements are beyond the limits has not been fully elucidated.For example,if a BPH treatment trial only includes patients with a maximum flow rate of less than 12ml/c and residual urines of less than250ml,the out-comes of a patient with measurem
ents greater than the limits are unknown.
MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA533
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There now is some evidence,however,to suggest that cer-tain tests may be valuable in predicting the respon to therapy in specific circumstances.Serum PSA measurement (as a proxy for prostate size)and ultrasound predict both the natural history and progression of LUTS and BPH and the therapeutic respon to 5alpha-reducta inhibitors.Be-cau minimally invasive therapies and transurethral inci-sion of the prostate (TUIP)are only effective in patients with prostates in a certain size range,the shape of the prostate (i.e.,the prence of a middle lobe)also may predict respon or lack thereof to certain minimally invasive or medical ther-apies.Although maximum flow-rate (a proxy for urodynamic studies)and invasive urodynamic studies have limited abil-ity to predict both natural history and therapeutic respon,they have been shown to predict the respon to surgery and,less so,minimally invasive therapies.The shape of the pros-tate as assd by cystoscopy (e.g.,lateral versus middle lobes)also may forecast the respon to minimally invasive and surgical therapies.Finally,PVR measurement predicts both natural history and treatment respon to all thera
pies to a limited extent.Optional:Additional diagnostic tests,such as pressure-flow urodynamic studies,urethrocystoscopy
and ultrasound (transrectal or transabdominal),are
optional in patients choosing invasive therapies,par-ticularly when the outcome of the pressure-flow study may impact choice of intervention or if prostate size and anatomical configuration are important consider-ations for a given treatment modality.They are not recommended in the initial evaluation of LUTS or in a tting other than tho described above.A pressure-flow urodynamic study ,although invasive,is the only test that directly measures the relative contribu-
tion of the bladder and bladder outlet and the contributions
of the prostate to lower urinary tract function,dysfunction or
symptoms.This study is not indicated to predict the respon
to medical therapy but is considered optional in men prior to invasive therapy.The 5th International Consultation on
BPH recommends uroflowmetry for all men who choo in-vasive or minimally invasive therapy followed by pressure-flow studies in tho men with a maximal urinary flow rate (Qmax)greater than 10ml/c when surgery is being consid-
ered.33Men with higher flow rates are less likely to be ob-structed and,therefore,less likely to benefit from surgical therapy.Pressure-flow studies also may be considered in the
evaluation of men with LUTS who have failed prior invasive therapy or who have concomitant neurologic dia known
to affect bladder function (e.g.,stroke,Parkinson ’s dia,
and neuropathy).The benefit of this study rests primarily in men with concomitant neurologic dia or a history of prior invasive therapy for BPH and in men in whom the physician believes that the study outcome would change the manage-ment strategy.
Urethrocystoscopy may be appropriate in men with a history of microscopic or gross hematuria,urethral stricture
(or risk factors,such as history of urethritis or urethral
injury),bladder cancer,or prior lower urinary tract surgery (especially transurethral rection of the prostate [TURP]).This test should not be ud in the initial evaluation of
patients without the risk factors or solely to determine the “need for treatment ”and is not routinely necessary prior to watchful waiting or medical therapy.The endoscopic appear-ance of the prostatic urethra and bladder does not predict the respon to BPH therapy.Nevertheless,the endoscopic ap-
pearance of the prostate anatomy may guide the choice of therapy in patients who have already decided to proceed with an invasive approach.
Transrectal or transabdominal prostate ultrasound may be an appropriate optional test when minimally invasive
or surgical interventions are chon as therapy.Ultrasound
examinations are not routinely necessary prior to watchful
waiting or medical therapy.The size and shape of the pros-tate are of importance in lecting patients for transurethral microwave heat treatment,TUNA and other minimally in-vasive therapies,as well as for the lection of TUIP versus TURP.Furthermore,anatomical features,such as intraves-ical
lobes,may impact the choice of therapy.Prostate size,as measured by ultrasound,is predictive of the natural history of BPH and the respon to therapy with 5alpha-reducta inhibitors.However,some patients may have a rum PSA measurement performed as part of the initial evaluation,and rum PSA as a proxy for prostate volume is also a strong predictor of natural history and respon to 5alpha-reducta inhibitor therapy.17,34
Not Recommended:Filling cystometrography (CMG)and imaging of the upper urinary tract by ul-trasonography or excretory urography are not recom-mended in the evaluation of the typical patient with symptoms of BPH unless the patient has hematuria,UTI,renal insufficiency,or a history of urolithiasis or urinary tract surgery.
The role of CMG and upper tract imaging is thoroughly reviewed in the 1994AHCPR guideline.29
TREATMENT RECOMMENDATIONS
青蛙简笔画In the first half of the 20th century,two treatment ap-proaches,both surgical,were available for BPH —open pros-tatectomy and TURP.With improvements such as fiber-optic lighting and the Hopkins rod lens wide-angle system,35TURP became the preferred treatment,not only for vere conditions condary to BPH,such as urinary retention and hydronephrosis,but for less vere yet bothersome
symp-T ABLE 1.1.Treatment options for patients with moderate to vere symptoms of benign prostatic hyperplasia Watchful Waiting Medical Therapies Alpha-adrenergic blockers Alfuzosin Doxazosin Tamsulosin Terazosin
5Alpha-reducta inhibitors Dutasteride*Finasteride Combination therapy (alpha blocker and 5alpha-reducta inhibi-tor)*,†Minimally Invasive Therapies Transurethral microwave heat treatments CoreTherm ™*Prostatron (various versions)
Targis TherMatrx ™*Transurethral needle ablation UroLume stent ‡Surgical Therapies Transurethral rection of the prostate Transurethral electrovaporization Transurethral incision of the prostate
Transurethral holmium lar rection/enucleation Transurethral lar vaporization Transurethral lar coagulation (e.g.,visual lar ablation)Open prostatectomy *Recommendations bad on randomized,controlled trials not included in the outcomes tables.
†The Panel assumes that the combination of any effective alpha blocker and 5alpha-reducta inhibitor probably produces a comparable benefit.However,the best-tested combination is doxazosin and finasteride.The safety of specific combinations other than finasteride plus doxazosin,terazosin,a
nd alfuzosin has not been assd.
‡Recommended for a subt of patients,e text.MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA 534For Internal U Only
toms,such as urgency and frequency.36Currently,at the beginning of this new century,TURP is still the benchmark therapy for BPH.36
Nonetheless,there are now many acceptable alternatives to TURP that are less costly per treatment episode,that require less time to produce positive outcomes,and that have less associated morbidity.The alternatives,which are listed in tables1.1and1.2,include medical therapies,such as alpha-adrenergic blockers,the minimally invasive options, such as transurethral microwave thermotherapy(TUMT), and the commonly utilized investigational treatments,offer patients a range of choices bad on the degree of their symptoms and the prence of uncommon or rious compli-cations.A brief discussion of the treatment options is pro-vided in the following ctions,and Chapter3(www.auane-t)provides the results of the evidence-bad,comparative outcomes analys of the therapies to the extent that the outcomes evidence was available.
Recommended therapies.Watchful Waiting:Watchful waiting is the preferred management strategy fo
r patients with mild symptoms.It is also an appropriate option for men with moderate to vere symptoms who have not yet devel-oped complications of ,renal insufficiency,urinary retention or recurrent infection).
Watchful waiting is a management strategy in which the patient is monitored by his physician but receives no active intervention for BPH.The level of symptom distress that individual patients are able to tolerate is highly variable so that watchful waiting may be a patient’s treatment of choice even if he has a high AUA Symptom Index or IPSS score.8,37 Symptom distress may be reduced with such simple meas-ures as decreasing fluid intake at bedtime and decreasing caffeine and alcohol intake generally.Watchful waiting pa-tients usually are reexamined yearly,repeating the initial evaluation outlined in figure1.1.
As prostate volume assd by DRE and/or rum PSA predicts the natural history of symptoms,flow rate,and risk for acute urinary retention and surgery,patients may be advid as to their individual risk depending on the outcomes of the asssments.Measures to reduce the risk,such as medical intervention,may be offered depending on the cir-cumstances.
Medical Treatment:The medical therapies for BPH ex-amined by the Panel were alpha-adrenergic bl
ockers,5 alpha-reducta inhibitors,combination therapies,and phy-totherapy(u of plant extracts).Medical therapies are not as efficacious as surgical therapies but may provide adequate symptom relief with fewer and less rious associated ad-ver events.37,38
Alpha-adrenergic blocker therapy
Option:Alfuzosin,doxazosin,tamsulosin and terazo-sin are appropriate treatment options for patients with LUTS condary to BPH.Although there are slight differences in the adver-event profiles of the agents,the Panel believes that all four agents have equal clinical effectiveness.
Guideline:Data are insufficient to support a recom-mendation for the u of prazosin or the nonlective alpha blocker phenoxybenzamine as treatment op-tions for LUTS condary to BPH.[The recommendation concerning phenoxybenzamine is bad on Panel expert opin-ion.]
Alpha-blocker therapy is bad on the hypothesis that clin-
ical BPH is partly caud by alpha
1-adrenergic-mediated
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contraction of prostatic smooth muscle,resulting in bladder outlet obstruction.39,40Alpha-adrenergic receptor antago-nists(blockers)such as doxazosin,tamsulosin,alfuzosin,and terazosin inhibit this process and thus relieve the bladder outlet obstruction.41
The u of alfuzosin,doxazosin,tamsulosin,and terazosin has been extensively investigated for the treatment of LUTS.Lepor notes that efficacy is do dependent for the titratable alpha blockers doxazosin and terazosin—the higher the do, the greater the obrved improvement.37Maximum tolerable and effective dos have not been defined for any alpha blocker,but reported clinical data support the efficacy and safety of titrating patients to8mg of doxazosin,to0.8mg of tamsulosin(from0.4mg),and to10mg of terazosin.The primary adver events reported with alpha-blocker therapy are orthostatic hypotension,dizziness,tiredness(asthenia), ejaculatory problems,and nasal congestion.The New Drug Application for the alpha blocker alfuzosin has been ap-proved by the FDA.Meta-analyzed data from the Panel’s evidence-bad review suggest that alfuzosin,doxazosin, tamsulosin,and terazosin are similarly effective in partially relieving symptoms,producing on average a4-to-6point im-provement in the AUA Symptom Index.In general,patients will perceive this level of symptom improvement as a mean-ingful change.42Trials directly comparing alpha blockers either are of short duration,or u inappropriate dosages or nonsta
ndardized outcome measures.43–46However,the Panel did u Bayesian techniques to create such comparisons us-ing the data that compare each of the alpha blockers with placebo.The resulting comparisons are detailed in Chapter3 (www.auanet).The adver event profile appears slightly different between the four alpha-blocking agents,for exam-ple,tamsulosin appears to have a lower probability of ortho-static hypotension but a higher probability of ejaculatory dysfunction than the other alpha blockers.Large,well-designed,direct comparator trials are needed to substantiate claims of superior safety.
In men with hypertension and cardiac risk factors,doxazo-sin monotherapy was associated with a higher incidence of congestive heart failure than en with other antihyperten-sive agents.47Bad upon the findings,u of an alpha blocker to manage a patient’s LUTS should not necessarily be assumed to constitute optimal management of the patient’s concomitant hypertension.In the cas,patients with hy-pertension may require parate management of their hyper-tension.
5Alpha-reducta inhibitor therapy
Option:The5alpha-reducta inhibitors finasteride and dutasteride are appropriate and effective treat-ments for patients with LUTS associated with demon-strable prostatic enlargement.
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Option:Patients with symptomatic prostatic en-largement but without signs of bother may be offered a5alpha-reducta inhibitor to prevent progression of the dia.However,the disadvantages of this therapeutic ,side effects such as xual dysfunction)and the need for long-term daily therapy should be prented to the patient in comparison to a reasonable estimate of his baline risk of progression (i.e.,retention and the risks associated with BPH-related surgery)so that an informed decision can be made.
Guideline:5Alpha-reducta inhibitors are not ap-propriate treatments for men with LUTS who do not have evidence of prostatic enlargement.
Finasteride(and other5alpha-reducta inhibitors shown in randomized,clinical trials to be equally effective in reduc-ing prostatic size)is an appropriate BPH treatment option. Finasteride is less effective than an alpha blocker in improv-ing LUTS and is not an appropriate treatment for men with LUTS who do not have prostatic enlargement.Finasteride reduces the risk of acute urinary retention and the need for BPH-related surgery.17
A5alpha-reducta inhibitor is the sole hormonal therapy, to date,that demonstrates both efficacy and acceptable safety for treatment of BPH.48Finasteride can reduce the size of the prostate,can increa peak urinary flow rate,and can reduce BPH symptoms.49It lowers rum and intrapros-
MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA535
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