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CUA guideline: LUTS/BPH

can also be obtained from a recent abdominal computed with their BPO. Physicians should assess either progression
tomography (CT) or magnetic resonance imaging (MRI). of bother, i.e., validated questionnaire such as IPSS (sub-
jective) or worsening urinary function, i.e., uroflowmetry
2. Treatment guidelines or PVR (objective).

Medical therapy
2.1 Principles of treatment Patients started on medical therapy should have followup
visit(s) to assess for efficacy and safety (side effects) of medi-
Therapeutic decision-making should be guided by the sever- cations. If the patient-directed therapeutic goal is achieved,
ity of the symptoms, the degree of bother, and patient prefer- the patient may be followed by the primary care physician as
ence. Information on the risks and benefits of BPH treatment part of a shared-care approach. The primary care physician
options should be explained to all patients who are bothered should be counselled with clear instructions on followup
enough to consider therapy. Patients should be invited to and re-referral as necessary.
participate as much as possible using a shared decision-
making approach to determine the best treatment selection Surgical therapy
for them. This can be facilitated with the use of the CUA Patients who receive prostate surgery for BPH should be
surgical BPH decision aid. The patient’s therapeutic goal of reviewed 4–6 weeks after catheter removal to evaluate treat-
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management should be discussed and documented. ment response (with symptom assessment [e.g., IPSS], and
Patients with mild symptoms (e.g., IPSS <7) should be if indicated, uroflowmetry and PVR volume). Side effects
counselled about a combination of lifestyle modification and and adverse events should also be screened for. The indi-
watchful waiting. Patients with mild symptoms and severe vidual patient’s circumstances and type of surgical procedure
bother should undergo further assessment. employed will determine the need for and type of further fol-
Treatment options for patients with bothersome moderate lowup required by the urologist and/or primary care physician.
(e.g., IPSS 8–18) and severe (e.g., IPSS 19–35) symptoms of
BPH include watchful waiting/lifestyle modification, as well 2.3 Medical therapy
as medical, minimally invasive, or surgical therapies.
Physicians should use baseline age, LUTS severity, and The committee recommended few changes in the recom-
prostate volume to advise patients of their individual risk mendations for the primary medical management of BPH
of symptom progression, acute urinary retention (AUR) or and MLUTS with alpha-blockers and/or 5-alpha-reductase
future need for BPH-related surgery (these risk factors iden- inhibitors (5ARIs) since 2018. Since the 2018 guideline pub-
tify patients at risk for progression). lication, new evidence is available in regard to other medical
A variety of lifestyle changes may be suggested for patients therapy, namely beta-3 agonists, for the treatment of MLUTS.
with non-bothersome symptoms. These can include:
- Fluid restriction, particularly prior to bedtime 2.3.1. Alpha-blockers
- Avoidance of caffeinated beverages, alcohol, and Alfuzosin, doxazosin, tamsulosin, terazosin, and silodosin
spicy foods are appropriate treatment options for LUTS secondary to
- Avoidance/monitoring of some drugs (e.g., diuretics, BPH. 12-23 Doxazosin and terazosin require dose titration
decongestants, antihistamines, antidepressants) and blood pressure monitoring. Alpha-blockers do not alter
- Timed or organized voiding (bladder retraining) the natural progression of BPH (little impact on prostate
- Avoidance or treatment of constipation growth, risk of urinary retention, or the need for BPH-related
- Weight loss and prevention or treatment of conditions surgery). The most common adverse effect associated with
associated with metabolic syndrome alpha-blockers is dizziness (2–10%, with the highest rates for
- Pelvic floor physical therapy (PFPT) in cases of sus- terazosin and doxazosin), while ejaculatory disturbances are
pected non-relaxing pelvic floor dysfunction (causing most often reported with tamsulosin and silodosin. Floppy
LUTS, pelvic and or genital pain, bowel and sexual iris syndrome has been reported in patients on alpha-block-
dysfunction, etc.) or overactive bladder and/or urinary ers, particularly tamsulosin, but this does not appear to be
incontinence (Kegel exercises, urge suppression, etc.) an issue in men with no planned cataract surgery and can
be managed by the ophthalmologist, who is aware that the
2.2. Post-treatment followup patient is on the medication. Although there are differences
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in the adverse event profiles of these agents, all five agents
Watchful waiting appear to have equal clinical effectiveness. The choice of
Patients on watchful waiting should have periodic physician- agent should depend on the patient’s comorbidities, side
monitored visits to monitor for any complications associated effect profile, and tolerance.

CUAJ • August 2022 • Volume 16, Issue 8 247