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Elterman et al

105
geous in prostate volumes >80 mL, and can be considered Detrusor underactivity
as a treatment for gross hematuria of prostatic origin. 106 There is no effective treatment for detrusor underactivity
(DU), defined as a contraction of reduced strength and/or
At centers with urological and radiological collaboration duration, resulting in prolonged bladder emptying and/or
and technical expertise, highly selected, well-informed a failure to achieve complete bladder emptying within a
patients may be offered PAE if they wish to consider an normal time span. 110 In primary DU, treatment approach
alternative treatment option. Patients should be informed should be to facilitate bladder emptying, identify agents that
of lack of long-term durability (conditional recommenda- can decrease bladder contractility, or increase urethral resist-
tion, evidence level C). ance. Behavioral modification, including scheduled voiding
Algorithms summarizing the management of a patient and or double voiding, clean intermittent self-catheterization
111
with MLUTS/BPH are summarized in Figures 2, 3. (CIC), or indwelling catheters, are optional strategies. The
data suggests that DU is not necessarily a contraindication
2.5. Special situations for TURP or enucleation. 112,113

AUR We have no evidence-based specific recommendation for
Data suggest that in patients with AUR, the use of alpha-block- management of DU.
ers (specifically tamsulosin, alfuzosin, and silodosin) during the
period of catheterization will increase the chances of success- BPH-related bleeding
ful voiding after catheter removal, 107,108 while the addition of A complete assessment, including history and physical
a 5-ARI may decrease the risk of future prostate surgery. 30,31,109 examination, urinalysis (routine microscopy, culture and
sensitivity, cytology), upper tract radiological assessment,
We suggest that men with AUR secondary to BPH may be and cystoscopy, is necessary to exclude other sources of
offered alpha-blocker therapy during the period of cath- bleeding. Finasteride has been reported to reduce the risk
eterization (conditional recommendation, evidence level B). of recurrent BPH-related hematuria. 114

MLUTS/BPH
Evaluation as per Fig. 1
Storage symptoms
only

• Lifestyle intervention Voiding (=storage symptoms) MIST
• Behavioural therapy or
Discuss Rx options surgery
• Antimuscarinics
• B3 agonist Shared decision as per Fig. 3
CUA BPH Decision Aid

Medical therapy
Nocturnal option
polyuria Failure
Predominant ED
voiding

Larger gland and/or
Antimuscarinic Small gland PDE5
DDAVP & and/or low PLS higher PSA α-blockers ± inhibitor
α-blockers α−blockers 5-α-reductase inhibitors

FAILURE
Figure 2. Male lower urinary tract symptoms/benign prostatic hyperplasia (MLUTS/BPH) management algorithm. ED: erectile dysfunction;
PDE5: phosphodiesterase type 5; PSA: prostate-specific antigen.

252 CUAJ • August 2022 • Volume 16, Issue 8