When medicines, when Op.?

Amongst the 50 most common ICD-10 key numbers in general practice, prostate hyperplasia (N40) ranks 40th (ZI Berlin 2008), making it the most commonly used urological diagnosis in general practice [9]. Primary diagnostics, clarification of the therapy indication as well as basic knowledge of the conservative and operative treatment options are important for the GP.

The abbreviation “BPH” is usually mistakenly used for bladder dysfunction in men. However, the term “benign prostatic hyperplasia” is strictly a histological diagnosis. The complaints complained of by the patient are internationally known as “LUTS” (lower urinary tract symptoms) (see Table 1). The terminology distinguishes the BPS from the symptom-descriptive term LUTS and the enlargement of the prostate (BPE). LUTS is not pathognomonic for BPS, as these symptoms are also described in overactive bladder syndrome (OAB). An OAB caused by the bladder tetrusor therefore precludes the presence of recognizable local pathologies such as BPH, BPE or BOO [1].

Epidemiology

According to the Herner-LUTS study published in 2001, 40.5% of the > 50-year-olds in Germany in need of treatment LUTS. Another 26.9% have an enlarged prostate (> 25 ml) and 17.3% have a markedly reduced urinary stream [4]. The BPS progresses chronically progressive with increasing LUTS and complications such as urinary retention or recurrent urinary tract infections.

The guidelines published in 2009 provide a systematic overview of the diagnosis and treatment of BPS [2, 3]. With appropriate complaints, the family doctor should ask the following questions:

Are the complaints attributable to the BPS?
There is a need for treatment?
Which therapy method is suitable?

Basic diagnosis in case of suspected BPS

General history: Important questions are hematuria, urinary tract infections, diabetes, heart failure and neurological diseases. In addition, trauma and previous operations should be recorded. The medication history is particularly important in neurological comorbidities.

Quantification of symptoms and quality of life: As a standardized evaluation of LUTS, the International Prostate Symptoms Score (IPSS) has prevailed [5]. IPSS values 7. The questionnaire can be downloaded from http://www.prostata-info.de/download/fb/ipss-fragebogen.pdf.

Physical examination: Here one should also raise an orienting neurological status. The digital rectal examination (DRU) assesses the prostate in terms of size, dolenz and consistency. Despite the low sensitivity of the DRU, a prostate biopsy to exclude prostate cancer is necessary in the case of a carcinoma-optic palpation. In addition, a urinalysis should be assessed by means of a stix or a microscopy for HWI and hematuria diagnostics should be performed.

Prostate Specific Antigen (PSA): The PSA determination serves primarily to exclude a prostate carcinoma. Special attention should be paid to altered PSA levels under 5α-reductase inhibitors, which decrease by about 50% under this therapy.

uroflowmetry: Uroflowmetry serves as a screening test for bladder emptying disorder. The maximum urine flow (Qmax) is volume-dependent, and in 90% of cases it is only a BOO from a micturition volume of 2 mm [16]. If intravesical tumors are suspected, a cystoscopy must be performed (Table 1).

therapy

No therapy without previous urological diagnosis.
Patient selection to avoid therapy cascades.
Control of therapeutic efficacy using IPSS, urine flow and residual urine.

Conservative therapy options

In the case of low or moderate symptoms and no impairment of the quality of life no active therapy is required [21]. However, in the case of unpredictable progression, the patient should be informed about the need for regular follow-up.

Medical therapy

Phytotherapy: The use of “herbal” medicines such as the extracts of sawtooth palm, nettle roots, pumpkin seeds and rye pollen is often done from the point of view of good tolerance and freedom from prescription. Despite evidence for the efficacy of four phytotherapeutics (? -Sitosterol, sawtooth palm, rye pollen, African plum tree) from randomized controlled trials, no evidence for long-term, clinically relevant efficacy has been provided as regards the prevention of progression or complications [8, 24, 25].

α1-adrenergic receptor antagonists: In Germany, four “α-blockers” are approved for the treatment of BPS: alfuzosin, doxazosin, tamsulosin and terazosin. The preparations differ in terms of selectivity for subtypes of α1-adrenoceptors as well as in their pharmacogenetics. The efficacy is the reduction of BPS symptoms. However, the impact on BPO, disease progression, or avoidance of urinary retention is low [13]. Side effects may include fatigue, dizziness, headache, flu symptoms, and hypertonic dysregulation. The administration of additional α-blockers for hypertension treatment is contraindicated.

5α-reductase inhibitors: These substances inhibit the breakdown of testosterone into the more effective DHT in the prostate. Dutasteride and finasteride are available. The active ingredients are considered equivalent in their efficacy and tolerability [14, 15]. 5α-reductase inhibitors reduce symptoms as well as prostate volume and PSA, but have no clinically relevant effect on the degree of obstruction. The PCPT study showed a risk reduction for prostate cancer and BPS complications [23]. Significant side effects include loss of libido, erectile dysfunction and gynecomastia.

Muscarinic receptor antagonists (anticholinergics): They are actually the standard treatment of OAB. However, the complex of symptoms of imperative urgency, pollakisuria, nocturia, and urge incontinence is also typical of BPS. The relaxing effect on smooth muscle increases the risk of urinary retention in patients with BPO. However, 40% of BPS patients are non-obstructive and could benefit from anticholinergic therapy by relieving imperative urgency and reduced micturition frequency. Side effects manifest in xerostomia and constipation.

Combination treatments with α-blockers and 5α-reductase inhibitors are suitable for inhibiting the progression of BPS and superior to monotherapy [13]. The combination of α-blockers and muscarinic receptor antagonists for the treatment of BPS symptoms can be used in patients without BPO to reduce the imperative urgency and the increased frequency of micturition [11] (see Table 2).

Operative therapy options

Absolute indications for BPO and BPS complications include recurrent urinary retention, recurrent urinary tract infections, uncontrollable hematuria, urinary bladder congestion and dilatation of the upper urinary tract, or impaired renal function.

TUR-Prostate: The TUR-P is the most frequently performed urological operation per year with approx. 75,000 interventions in Germany and is still regarded as a reference procedure. The main advantages of the TUR-P compared to more modern procedures are the better postoperative micturition parameters and the higher degree of desobstruction. On the other hand, the perioperative bleeding and the TUR syndrome (hypotonic hyperhydration). However, technical modifications such as “dry cut” or “bipolar resection” also show improvements in these areas with consistent postoperative results [7]. The transurethral incision of the prostate (TUIP) has been shown in several studies a more favorable side effect profile [18] and is mainly for sexually active men with a prostate volume 70 ml. Transurethral procedures such as holmium or Thuliumlaserenukleation show equieffective results with lower morbidity.

laser procedures

Laservaporisation by KTP “Green light laser” (Figures 1a and 1b) is a primary ablative procedure. Randomized studies have shown efficacy equivalency with lower morbidity [22]. The main advantage is the haemostatic effect of the procedure, which also allows the treatment of patients undergoing anticoagulation [17]. Disadvantages of the method are relatively low obstruction performance, prolonged dysuria episodes postoperatively and high costs.

laser enucleation: Holmium and thulium laser nucleation are available here (Fig. 2a and 2b). Here, the prostate tissue is transurethrally enucleated and then crushed intravesically and aspirated. The possibility of enucleation even of very large prostate volumes has already prophesied the “end” of open adenoma enucleation [12]. One major disadvantage is the considerable learning curve.

conclusion for practice

For the successful treatment of BPS, basic diagnostics as well as the quantification of the symptoms are the essential steps for the right therapy. Drug therapy requires detailed knowledge of possible uses and side effects. Modern minimally invasive surgical procedures are increasingly being used due to their reduced spectrum of side effects.

Published in: The GP, 2010; 32 (18) page 18-21

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