Page 3 - Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia (MLUTS/BPH): 2018 update

Guideline: Male LUTS/BPH

or future need for BPH-related surgery (these risk factors disturbances are most often reported with tamsulosin and
identify patients at risk for progression). silodosin. Floppy iris syndrome has been reported in patients
A variety of lifestyle changes may be suggested for on alpha-blockers, particularly tamsulosin, but this does not
patients with non-bothersome symptoms. These can include appear to be an issue in men with no planned cataract sur-
the following: gery and can be managed by the ophthalmologist, who is
– Fluid restriction, particularly prior to bedtime aware that the patient is on the medication. Although there
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– Avoidance of caffeinated beverages, alcohol, and are differences in the adverse event profiles of these agents,
spicy foods all five agents appear to have equal clinical effectiveness.
– Avoidance/monitoring of some drugs (e.g., diuretics, The choice of agent should depend on the patient’s comor-
decongestants, antihistamines, antidepressants) bidities, side effect profiles, and tolerance.
– Timed or organized voiding (bladder retraining) We recommend alpha-blockers as an excellent first-line
– Pelvic floor exercises therapeutic option for men with symptomatic bother who
– Avoidance or treatment of constipation desire treatment (strong recommendation based on high-
quality evidence).
2.2. Post-treatment followup
2.3.2. 5ARIs
Watchful waiting: Patients on watchful waiting should have Several studies have demonstrated that 5ARI therapy, in
periodic physician-monitored visits. addition to improving symptoms and causing a modest
Medical therapy: Patients started on medical therapy (25–30%) shrinkage of the prostate, can alter the natural his-
should have followup visit(s) to assess for efficacy and safety tory of BPH through a reduction in the risk of acute urinary
(side effects of medications). If the patient-directed thera- retention (AUR) and the need for surgical intervention. 24,25
peutic goal is achieved, the patient may be followed by the Efficacy is noted in patients with a prostate volume >30 cc
primary care physician as part of a shared-care approach. (and/or PSA levels >1.5 ng/ml). 5ARI treatment is associated
The primary care physician should be counselled with clear with erectile dysfunction, decreased libido, ejaculation dis-
instructions on followup and re-referral as necessary. orders, and rarely, gynecomastia.
Surgical therapy: Patients after prostate surgery should We recommend 5ARIs (dutasteride and finasteride) as
be reviewed 4–6 weeks after catheter removal to evaluate appropriate and effective treatment for patients with LUTS
treatment response (with symptom assessment [e.g., IPSS], associated with demonstrable prostatic enlargement (strong
and if indicated, uroflowmetry, and post-void residual [PVR] recommendation based on high-quality evidence).
volume) and adverse events. The individual patient’s circum-
stances and type of surgical procedure employed will deter- 2.3.3. Combination therapy (alpha-blocker and 5ARI)
mine the need for and/or type of further followup required Prognostic factors suggesting the potential for BPH progres-
by the urologist and/or primary care physician. sion risk 26,27 include: serum PSA >1.4 ng/mL, age >50 years,
and gland volume >30 cc. Clinical trial results have shown
2.3. Medical therapy that combination therapy significantly improves symptom
score and peak urinary flow compared with either of the
The committee recommended few change in the recommen- monotherapy options. Combination medical therapy is
dations for the primary medical management of BPH and associated with decreased risk of urinary retention and/or
MLUTS with alpha-blockers and/or 5-alpha-reductase inhibit- prostate surgery, but also the additive side effects of dual
ors (5ARIs) since 2010. Since the 2010 guideline publication, therapy (in particular ejaculatory disturbances). 28,29
new evidence is available in regard to other medical therapy, We recommend that the combination of an alpha-adrener-
including combination therapy, for the treatment of MLUTS. gic receptor blocker and a 5ARI as an appropriate and effect-
ive treatment strategy for patients with symptomatic LUTS
2.3.1. Alpha-blockers associated with prostatic enlargement (> 30 or 35 cc) (strong
Alfuzosin, doxazosin, tamsulosin, terazosin, and silodosin recommendation based on high-quality evidence).
are appropriate treatment options for LUTS secondary to It may be appropriate to consider discontinuing the alpha
BPH. 12-20,22,23 Doxazosin and terazosin require dose titra- blockers in patients successfully managed with combination
tion and blood pressure monitoring. Alpha-blockers do not therapy after 6–9 months of therapy. 30,31
alter the natural progression of the disease (little impact on We suggest that patients successfully treated with com-
prostate growth, the risk of urinary retention or the need bination therapy may be given the option of discontinuing
for BPH-related surgery). The most common adverse effect the alpha-blocker. If symptoms recur, the alpha-blocker
associated with alpha-blockers is dizziness (2–10%, with the should be restarted (conditional recommendation based
highest rates for terazosin and doxazosin), while ejaculatory on moderate-quality evidence).

CUAJ • October 2018 • Volume 12, Issue 10 305