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BENIGN PROSTATIC HYPERPLASIA (BPH)

Population

  • Adult men age >45 with lower urinary tract symptoms (LUTS) from prostatic enlargement.

Recommendations

AUA 2010

  • Do not routinely measure serum creatinine in men with BPH.

  • Do not recommend dietary supplements or phytotherapeutic agents for LUTS management.

  • Patients with LUTS and no signs of bladder outlet obstruction by flow study should be treated for detrusor overactivity.

    • Alter fluid intake.

    • Behavioral modification.

    • Anticholinergic medications.

  • Options for moderate-to-severe LUTS from BPH (AUA symptom index score ≥8).

    • Watchful waiting.

    • Medical therapies.

      • Alpha-blockers.a

      • 5-Alpha-reductase inhibitors.b

      • Anticholinergic agents.

      • Combination therapy.

    • Transurethral needle ablation.

    • Transurethral microwave thermotherapy.

    • Transurethral laser ablation or enucleation of the prostate.

    • Transurethral incision of the prostate.

    • Transurethral vaporization of the prostate.

    • Transurethral resection of the prostate.

    • Laser resection of the prostate.

    • Photoselective vaporization of the prostate.

    • Prostatectomy.

  • Surgery is recommended for BPH causing renal insufficiency, recurrent urinary tract infections (UTIs), bladder stones, gross hematuria, or refractory LUTS.

Source

Comments

  1. Combination therapy with alpha-blocker and 5-alpha-reductase inhibitor is effective for moderate-to-severe LUTS with significant prostate enlargement.

  2. Men with planned cataract surgery should have cataract surgery before initiating alpha-blockers.

  3. 5-Alpha-reductase inhibitors should not be used for men with LUTS from BPH without prostate enlargement.

  4. Anticholinergic agents are appropriate for LUTS that are primarily irritative symptoms, and if patient does not have an elevated post-void residual (>250 mL).

  5. The choice of surgical method should be based on the patient’s presentation, anatomy, surgeon’s experience, and patient’s preference.

aAlfa-blockers: alfuzosin, doxazosin, tamsulosin, and terazosin. All have equal clinical effectiveness.

b5-Alfa-reductase inhibitors: dutasteride and finasteride.

ERECTILE DYSFUNCTION (ED)

Population

  • Adult men.

Recommendations

EAU 2018, Endocrine Society 2018

  • Perform a medical and psychosexual history on all patients.

  • Perform a focused physical examination to assess CV status, neurologic status, prostate disease, penile abnormalities, and signs of hypogonadism.

  • Recommend exercise and decreased BMI.

  • Check a fasting glucose, lipid profile, and morning fasting total testosterone levels.

  • Refer for psychosexual therapy if psychogenic ED.

  • Offer testosterone therapy for androgen deficiency if no contraindications are present.c

  • Selective phosphodiesterase 5 (PDE5) inhibitors are first-line therapy for idiopathic ED.

  • If PDE5 fail, consider intercavernosal injections or penile prosthesis.

Sources

Comments

  1. Selective PDE5 inhibitors:

    1. Sildenafil (100 mg, half-life 2–4 h).

    2. Tadalafil (20 mg, half-life 18 h).

    3. Vardenafil (20 mg, half-life 4 h).

    4. Avanafil (200 mg, half-life 6–17 h).

  2. Avoid nitrates and use alpha-blockers with caution when prescribing a selective PDE5 inhibitor.

cProstate CA, breast CA, signs of prostatism, men who intend fertility ...

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