Page 2 - Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia (MLUTS/BPH): 2018 update

Nickel et al

1.3. Optional 1.5. Further diagnostic considerations for surgery

In cases where the physician feels it is indicated or diagnos- Indications for surgery: Indications for MLUTS/BPH sur-
1-3
tic uncertainty exists, it is reasonable to proceed with one gery include a) recurrent or refractory urinary retention;
or more of the following: b) recurrent urinary tract infections (UTIs); c) bladder stones;
– Serum creatinine d) recurrent hematuria; e) renal dysfunction secondary to
– Urine cytology BPH; f) symptom deterioration despite medical therapy; and
– Uroflowmetry g) patient preference. The presence of a bladder diverticulum
– Post-void residual is not an absolute indication for surgery unless associated
– Voiding diary (recommend frequency volume chart with recurrent UTI or progressive bladder dysfunction.
for men with suspected nocturnal polyuria) Preoperative testing: Determination of prostate size and
– Sexual function questionnaire extent of median lobe are related to procedure-specific
indications (see section on Surgical Treatment). Cystoscopy
1.4. Not recommended should be performed to evaluate prostate size, as well as
presence or absence of significant middle/median lobe.
The following diagnostic modalities are not recommended Ultrasound (US) (either by transrectal ultrasound [TRUS] or
in the routine initial evaluation of a typical patient with transabdominal US) is recommended if further information
BPH-associated LUTS. These investigations may be required in regard to size of prostate and extent of median lobe pres-
in patients with a definite indication, such as hematuria, ence is required when choosing modality of surgical therapy.
uncertain diagnosis, DRE abnormalities, poor response to
medical therapy, or for surgical planning. 2. Treatment guidelines
– Cytology
– Cystoscopy
– Urodynamics 2.1. Principles of treatment
– Radiological evaluation of upper urinary tract
– Prostate ultrasound Therapeutic decision-making should be guided by the sever-
– Prostate biopsy ity of the symptoms, the degree of bother, and patient prefer-
An algorithm summarizing the appropriate diagnostic steps ence. Information on the risks and benefits of BPH treatment
in the workup of a typical patient with MLUTS/BPH is options should be explained to all patients who are bothered
shown in Fig. 1. enough to consider therapy. Patients should be invited to
participate as much as possible in the treatment selection.
Patients with mild symp -
toms (e.g., IPSS <7) should be
Typical man presenting with LUTS
counselled about a combina-
tion of lifestyle modification
Mandatory assessment and watchful waiting. Patients
History
Focused PE with mild symptoms and severe
U/A bother should undergo further
assessment.
Treatment options for
Recommended Indications for surgery patients with bothersome
Symptom inventory moderate (e.g., IPSS 8–18) and
PSA (selected)
severe (e.g., IPSS 19–35) symp-
toms of BPH include watchful
Mild symptoms Moderate/severe symptoms Other diagnostic tests as necessary
No bother (cystoscopy, urodynamics) waiting/lifestyle modification,
as well as medical, minimally
OPTIONAL invasive, or surgical therapies.
Creatinine
Urine cytology Physicians should use base-
Uroflow line age, LUTS severity, prostate
PVR volume, and/or serum PSA to
Sexual function questionnaire
advise patients of their individ-
Fig. 1. Algorithm of appropriate diagnostic steps in the workup of a typical patient with male lower urinary tract ual risk of symptom progres -
symptoms/benign prostatic hyperplasia (LUTS/BPH). PE: physical exam; PSA: prostate-specific antigen; PVR: post-void sion, acute urinary retention
residual; U/A: urinalysis.

304 CUAJ • October 2018 • Volume 12, Issue 10