Chapter 32: Genitourinary Disorders

BENIGN PROSTATIC HYPERPLASIA (BPH)

Population

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

Recommendations

AUA 2010, 2019

• – 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, refractory retention secondary to BPH, recurrent urinary tract infections (UTIs), bladder stones, gross hematuria, refractory LUTS, and/or those unwilling to use other therapies.

Sources

• – http://www.guidelines.gov/content.aspx?id=25635&search=aua+2010+bph

• – https://www.auanet.org/guidelines/benign-prostatic-hyperplasia-(bph)-guideline

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.

CERVICAL CANCER AND ABNORMAL PAP

Population

• – Women with abnormal cervical cancer screening studies.

Recommendations

ASCCP 2017, 2019

• – Manage abnormal results by assessing risk of CIN3 or higher grade lesion.

• – If immediate CIN3+ risk is >4%, intervene.

  • 60%–100%: Expedited treatment^c

  • 25%–59%: Expedited treatment or colposcopy

  • 4%–24%: Colposcopy

• – If immediate CIN3+ risk <4%, choose surveillance interval based on 5-y CIN3+ risk.

  • >0.55%: Return in 1 y.

  • 0.15%–0.54%: Return in 3 y.

  • <0.15%: Return in 5 y.

• – Follow-up intervals or treatment pathways are determined by pap and HPV results as well as recent history (Tables 32-1 and 32-2).

• – When performing colposcopy, obtain 2–4 targeted biopsies of acetowhite lesions.

• – Obtain endocervical sample if unable to visualize entire lesion or squamocolumnar junction.

• – If low-risk (cytology <LSIL, no HPV 16/18, and no anomalies on colposcopy), do not obtain random nontargeted biopsies.

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