BPH patient assessment

LUTS and BPH

Lower urinary tract symptoms (LUTS) are frequently associated with benign prostatic enlargement or benign prostatic hyperplasia (BPE or BPH). LUTS are broadly categorized as problems of either bladder emptying (voiding and postmicturation) or bladder storage. Emptying problems usually ascribed to the mechanical impact of an enlarged prostatic transitional zone (benign prostatic obstruction – BPO). Storage problems include irritative functional symptoms such as frequency, urgency, urge incontinence, and nocturia due to the obstruction of the bladder by the hyperplastic prostate. These storage symptoms have significantly more impact on the quality of life (QoL) than voiding symptoms, and nocturia is one of the most bothersome as it induces sleep disturbances.

Patient assessment before PAE

Patients presenting with LUTS/BPH are usually over 50 years of age (mostly above their 60’s). Patient assessment should include subjective and objective parameters at baseline and at follow-up post-PAE.

Subjective parameters evaluate LUTS, sexual function and continence with specific validated questionnaires that try to quantify the subjective symptomology. International Prostate Symptom Score (IPSS) is an eight question clinical instrument consisting of seven symptom questions plus one quality of life question (QoL) and is intended for self-administration by the patient and quantifies LUTS. The 5-question International Index of Erectile Function (IIEF-5) measures erectile function in men. The Male Sexual Health Questionnaire Ejaculatory Function (MSHQ-EjD) Short assesses ejaculatory function. The Incontinence Severity Index (ISI) categorizes urinary incontinence into slight, moderate, severe, and very severe. Bladder diaries are also useful when evaluating LUTS patients. These are all self-administered questionnaires that provide a lot of information about LUTS, sexual function in both erectile and ejaculatory domains and irritative/storage symptoms severity/incontinence.

Objective parameters that should be evaluated include: blood tests with prostate specific antigen (PSA) measurements; urine analysis; prostate volume assessment with ultrasound; peak urinary flowrate (Qmax) with uroflowmetry and post-void residual urine volume assessment with bladder ultrasound. Kidney ultrasound is also recommendable.

When counselling patients for a potential PAE, all of these parameters should be evaluated to rule out prostate, bladder or kidney cancer, non-BPH causes of LUTS or dysfunctional bladder. Prostatic medication should be discussed with the patients, as well as available minimally invasive therapies and ressective surgical options to treat LUTS-BPH. Patient´s expectations regarding LUTS, sexual function, continence, recovery time and adverse events should be accounted for when discussing all available invasive therapies for BPH. In specific scenarios, invasive urodynamic studies, prostate MR and prostate biopsy might be needed. Adverse events and clinical outcomes expectable after PAE should also be discussed prior to PAE and should be part of the written informed consent form.

Medical therapies for BPH-LUTS

Medical therapy is the first-line treatment approach for patients with BPH-LUTS. α1- Adrenoceptor antagonists (α1-blockers) are the most frequently prescribed medications for LUTS relief. α1-blockers reduce the muscle tone of the smooth muscle cells within the prostate, with an almost immediate (e.g., hours to days) reduction of LUTS, with no effect on prostate volume and disease progression. 5-alpha-reductaseinhibitors (5-ARIs) are also frequently prescribed drugs for patients with BPO and LUTS. 5-ARIs induce apoptosis of prostatic epithelial cells, inducing a prostate volume reduction of approximately 20–25% and a PSA reduction of 50%. Unlike a1-blockers, 5-ARIs take weeks to months to have an effect, with 1–6 months of washout period, thus they are only considered for long-term use. They have a modest impact on LUTS severity but prevent disease progression (acute urinary retention and need for surgery) and are recommended for patients with prostate volumes > 40 cm3. However, 5-ARIs have non-neglectable side effects that limit their use in some patients, including: reduced libido, erectile dysfunction and ejaculatory dysfunction. Gynecomastia develops in 1–2% of treated patients.

Invasive therapies for BPH-LUTS

Minimally invasive therapies (MITs) for BPH-LUTS encompass prostatic artery embolization (PAE), water vapor thermal therapy (Rezum), prostatic urethral lift (PUL), iTIND  (temporary implantable device) and aquablation (Aquabeam). Surgical ressective techniques include trans-urethral resection of the prostate (TURP), open, robotic and laser prostatectomy. The advantages of MITs over ressective surgery include faster recovery times with lower adverse events rates and preservation of sexual function and continence status. The advantages of surgical ressective techniques include more robust improvements in Qmax, greater prostate volume and PSA reductions, with lower re-intervention rates in the longterm. LUTS relief seems to be similar between PAE and TURP. Limited data exists comparing the different MISTs.