Page 4 - Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia (MLUTS/BPH): 2018 update

Nickel et al

2.3.4. Antimuscarinic and beta-3 agonist medications We recommend desmopressin as a therapeutic option in
Storage symptoms (urgency, frequency, nocturia) are a men with MLUTS/BPH with nocturia as result of nocturnal
bothersome component of MLUTS associated with BPH. polyuria (conditional recommendation based on moderate-
Antimuscarinics (anticholinergics) and the beta-3 agonist quality evidence).
have demonstrated improvements in male storage LUTS
(with and without BPH), including reductions in frequency, 2.3.7. Phytotherapies
urgency, and urgency incontinence episodes. 32,33 Studies Plant-based herbal preparations may appeal to some
of contemporary antimuscarinics, such as tolterodine and patients. Common formulations include Serenoa repens
fesoterodine and the beta-3 agonist, mirabegron have shown (saw palmetto), Pygeum africanum (African plum bark), and
low rates of urinary retention, although caution may be used Urtica dioica (stinging nettle). Phytotherapies lack consistent
in elderly men and those with significant bladder outlet formulation, predictable pharmacokinetics, and regulatory
obstruction (BOO) (with PVR >250–300 cc since there is oversight. Numerous studies and Cochrane meta-analyses
little evidence of safety in men with high PVRs). report no significant difference between phytotherapies and
We suggest that antimuscarinics or beta-3 agonists may placebo, as measured by AUA-SI, peak flow rates, prostate
be useful therapies in MLUTS/BPH with caution in those volume, residual urine volume, PSA, or quality of life. 38-41
with significant BOO and/or PVR (conditional recommen- There are few side effects associated with phytotherapies.
dation based on low-quality evidence). We do not recommend phytotherapies as standard treat-
Evidence shows that alpha-blocker combination with ment for MLUTS/BPH (moderate recommendation based
antimuscarinics can benefit some men with both voiding and on high-quality evidence).
storage symptoms, while antimuscarinic and beta-3 agonist
combination therapies can be beneficial in some men with 2.4. Surgical therapy
significant storage symptoms. 34,35
We suggest that that alpha-blocker combination with 2.4.1. Transurethral resection of the prostate (TURP)
antimuscarinics or beta-3 agonists may be useful therapies Monopolar TURP (M-TURP): M-TURP remains the primary,
in MLUTS/BPH in some men (failure of alpha blocker mono- standard-reference surgical treatment option for moderate
therapy) with both voiding and storage symptoms (condi- to severe LUTS due to BPH in patients with prostate vol -
42
tional recommendation based on low-quality evidence). ume 30–80 cc. Perioperative mortality has decreased over
time (0.1%), while morbidity is related to prostate volume
2.3.5. Phosphodiesterase inhibitors (particularly >60 cc). Contemporary series have reported
43
Phosphodiesterase type 5 inhibitors (PDE5Is) have been the following complications: bleeding (2–9%), capsule per-
shown to not only improve erectile function, but also are foration with significant extravasation (2%), TUR syndrome
an effective treatment for male LUTS. Tadalafil 5 mg daily, (0.8%), urinary retention (4.5–13%), infection (3–4%; sep-
due to its longer half-life, is approved for male LUTS. Studies sis 1.5%), incontinence (<1%), bladder neck contracture
have shown improvements in IPSS, storage and voiding (3–5%), retrograde ejaculation (65%), erectile dysfunction
symptoms, and quality of life. 36 (6.5%), and surgical retreatment (2%/year). 44,45
We recommend long-acting PDE5Is as therapy for men We recommend M-TURP as a standard first-line sur -
with MLUTS/BPH, particularly men with both MLUTS and gical therapy for men with moderate to severe MLUTS/BPH
erectile dysfunction (strong recommendation based on with prostate volume of 30–80 cc (strong recommendation
high-quality evidence). based on high- to moderate-quality evidence).
Bipolar TURP (B-TURP): B-TURP offers a resection alterna-
2.3.6. Desmopressin tive to M-TURP in men with moderate to- severe LUTS sec-
Nocturnal polyuria often coexists with MLUTS and BPH, ondary to BPH with similar efficacy, but lower perioperative
45
but may not respond to typical BPH pharmacotherapies. morbidity. The choice of B-TURP should be based on equip-
Desmopressin is a synthetic analogue of the antidiur - ment availability, surgeon experience, and patient preference.
etic hormone, arginine vasopressin (AVP). Desmopressin We recommend B-TURP as a standard first-line surgical
reduces total nocturnal voids and increases hours of undis- therapy for men with moderate to severe MLUTS/BPS with
turbed sleep by reducing urine production in men with prostate volume of 30–80 cc (strong recommendation
nocturnal polyuria. While the risk of hyponatremia is based on moderate- to high-quality evidence).
37
low in men with normal baseline serum sodium, sodium Bipolar plasma kinetic vaporization (BPKVP): Also known
must be checked at baseline in all men, and 4–8 days as as the “plasma button” procedure, BPKVP is an alternative
well as 30 days after initiation of treatment in men taking to TURP. This procedure uses a mushroom-shaped axipolar
desmopressin melts or men ≥65 years taking 50 μg oral electrode to apply low-temperature radiofrequency plasma
disintegrating tablet. energy to vaporize prostate tissue on contact. Comparable

306 CUAJ • October 2018 • Volume 12, Issue 10