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Update on AUA Guideline on the Management of Benign Prostatic Hyperplasia Kevin T. McVary,* Claus G. Roehrborn, Andrew L. Avins, Michael J. Barry, Reginald C. Bruskewitz, Robert F. Donnell, Harris E. Foster, Jr., Chris M. Gonzalez, Steven A. Kaplan, David F. Penson, James C. Ulchaker and John T. Wei From the American Urological Association Education and Research, Inc., Linthicum Maryland Purpose: To revise the 2003 version of the American Urological Association’s (AUA) Guideline on
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  Update on AUA Guideline on the Management of BenignProstatic Hyperplasia Kevin T. McVary,* Claus G. Roehrborn, Andrew L. Avins, Michael J. Barry,Reginald C. Bruskewitz, Robert F. Donnell, Harris E. Foster, Jr., Chris M. Gonzalez,Steven A. Kaplan, David F. Penson, James C. Ulchaker and John T. Wei From the American Urological Association Education and Research, Inc., Linthicum Maryland  Purpose:  To revise the 2003 version of the American Urological Association’s(AUA) Guideline on the management of benign prostatic hyperplasia (BPH). Materials and Methods:  From MEDLINE® searches of English language publi-cations (January 1999 through February 2008) using relevant MeSH terms,articles concerning the management of the index patient, a male  45 years of agewho is consulting a healthcare provider for lower urinary tract symptoms (LUTS)were identified. Qualitative analysis of the evidence was performed. Selectedstudies were stratified by design, comparator, follow-up interval, and intensity of intervention, and meta-analyses (quantitative synthesis) of outcomes of random-ized controlled trials were planned. Guideline statements were drafted by anappointed expert Panel based on the evidence. Results:  The studies varied as to patient selection; randomization; blinding mechanism; run-in periods; patient demographics, comorbidities, prostate char-acteristics and symptoms; drug doses; other intervention characteristics; com-parators; rigor and intervals of follow-up; trial duration and timing; suspectedlack of applicability to current US practice; and techniques of outcomes measure-ment. These variations affected the quality of the evidence reviewed making formal meta-analysis impractical or futile. Instead, the Panel and extractorsreviewed the data in a systematic fashion and without statistical rigor. Diagnosisand treatment algorithms were adopted from the 2005 International Consulta-tion of Urologic Diseases. Guideline statements concerning pharmacotherapies,watchful waiting, surgical options and minimally invasive procedures were eitherupdated or newly drafted, peer reviewed and approved by AUA Board of Directors. Conclusions:  New pharmacotherapies and technologies have emerged whichhave impacted treatment algorithms. The management of LUTS/BPH continuesto evolve. Key Words:  prostatic hyperplasia, urinary retention, adrenergic alpha-antagonists, 5-alpha-reductase inhibitors, behavior therapy, transurethralresection of prostate The complete guideline is available at  www.AUAnet.org/BPH2010 .This document is being reprinted as submitted without independent editorial or peer review by the Editors of  The Journal of Urology  .* Correspondence: Tarry Building, 16 th Floor, 303 E. Chicago Ave., Chicago, Illinois 60611-3008 (telephone: 312- 908-1987; FAX: 312-908-7275;e-mail: k-mcvary@northwestern.edu). Abbreviationsand Acronyms 5-ARIs  5-alpha-reductaseinhibitorsBOO  bladder outlet obstructionBPH  benign prostatichyperplasiaCAM  complementary andalternative medicationsED  erectile dysfunctionHoLRP/HoLEP/HoLAP  holmiumlaser resection/enucleation/ablation of the prostateIFIS  intraoperative floppy irissyndromeLUTS  lower urinary tractsymptomsPSA  prostate specific antigenQoL  quality of lifeTUIP  transurethral incision ofthe prostateTUMT  transurethral microwavethermotherapyTUNA  transurethral needleablation of the prostateTURP  transurethral resection ofthe prostateTUVP  transurethral vaporizationof the prostateUTI  urinary tract infection B ENIGN  prostatic hyperplasia is a his-tologic diagnosis that refers to smoothmuscle and epithelial cell prolifera-tion within the prostatic transitionzone. 1 The enlarged gland has beenproposed to contribute to lower uri- 0022-5347/11/1855-1793/0 Vol. 185, 1793-1803, May 2011THE JOURNAL OF UROLOGY  ® Printed in U.S.A.© 2011 by A MERICAN  U ROLOGICAL  A SSOCIATION  E DUCATION AND  R ESEARCH , I NC . DOI:10.1016/j.juro.2011.01.074  www.jurology.com  1793  nary tract symptom via at least two routes (1) directbladder outlet obstruction (static component) and (2)increased smooth muscle tone and resistance (dy-namic component). In the management of bothersomeLUTS, it is important that healthcare providers recog-nize the complex interactions of the bladder, bladderneck, prostate and urethra, and that symptoms mayresult from interactions of these organs as well as thecentral nervous system. The 2010 BPH Guidelineattempts to acknowledge that LUTS represents abroad spectrum of etiologies, and focuses on themanagement of such symptoms.LUTS in the aging male can have a marked im-pact on individual health and society at large. 2,3  Although LUTS secondary to BPH (LUTS/BPH) isnot often life-threatening, the impact of LUTS/BPHon quality of life can be significant. Traditionally,the primary treatment goal has been to alleviatebothersome LUTS. More recently, treatment has ad-dressed the prevention of disease progression. 4 ThisGuideline reviews a number of important aspects inthe management of LUTS/BPH including diagnostictests to identify the underlying pathophysiology andsymptom management. Complementary and alter-native medications, watchful waiting, and lifestyleissues are addressed. The current literature on thestandard surgical options and on minimally invasiveprocedures is also reviewed.Recently,theassociationbetweenLUTSanderec-tile dysfunction has been clarified. Lifestyle factors –such as exercise, weight gain and obesity – alsoappear to have an impact on LUTS. We expect theserisk factors to grow in importance with the aging of the male population and the obesity epidemic. Theexpected increase in prevalence will place increaseddemands on the health system and put a premiumon efficient, evidence-based management in bothprimary and specialty care. DEFINITIONS AND TERMINOLOGY For the 2010 Guideline,  the Index Patient  is amale  45 years of age who is consulting a qualifiedhealthcare provider for his LUTS. He does not havea history suggesting non-BPH causes of LUTS andhis LUTS may or may not be associated with anenlarged prostate gland, BOO, or histological BPH. Lower urinary tract symptoms  include storageand/or voiding disturbances common in aging menand can be due to structural or functional abnormal-ities in one or more parts of the LUT or abnormali-ties of the peripheral and/or central nervous systemsthat provide neural control of the LUT. LUTS mayalso be secondary to cardiovascular, respiratory orrenal disease. METHODOLOGY The 2010 guideline statements were based on a sys-tematic review and synthesis of the literature oncurrent therapies for the treatment of BPH. Themethodology followed the same process used in thedevelopment of the 2003 Guideline and, as such, didnot include an evaluation of the strength of the bodyof evidence as will be instituted in future Guidelinesproduced by the American Urological Association.The full Guideline document including methodologycan be accessed at http://www.auanet.org/content/ guidelines-and-quality-care/clinical-guidelines.cfm.The guideline statements (indicated as boldedtext in this paper) were drafted by the Panel basedon evidence and tempered by the Panel’s expertopinion. As in the previous Guideline, these state-ments were graded using three levels of flexibility intheir application. A “standard” has the least flexibil-ity as a treatment policy; a “recommendation” hassignificantly more flexibility; and an “option” is evenmore flexible. DIAGNOSTIC EVALUATIONOF THE INDEX PATIENT  After review of the recommendations for diagnosispublished by the 2005 International Consultation of Urologic Diseases 5 and reiterated in 2009 6 , thePanel unanimously agreed that the contents remain valid and reflected “best practices.” The diagnosticguidelines can be found at  www.AUAnet.org/ BPH2010 . Basic Management The algorithm describing basic management classi-fies diagnostic tests as either recommended (shouldbe performed on every patient during the initialevaluation) or optional (test of proven value in theevaluation of select patients) (fig. 1). In general, optional tests are performed during a detailed eval-uationbyaurologist.Iftheinitialevaluationrevealsthe presence of LUTS associated with results of adigital rectal exam suggesting prostate cancer, he-maturia, abnormal prostate-specific antigen levels,recurrent urinary tract infection, palpable bladder,history/risk of urethral stricture, and/or a neurolog-ical disease raising the likelihood of a primary blad-der disorder, the patient should be referred to aurologist for appropriate evaluation before treat-ment. Baseline renal insufficiency appears to be nomore common in men with BPH than in men of thesame age group in the general population. Not Recommended: The routine measure-ment of serum creatinine levels is not in-dicated in the initial evaluation of menwith LUTS secondary to BPH. AUA GUIDELINE ON MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA 1794  [Based on review of the data and Panelconsensus.] The physician can discuss the benefits and risksof treatment alternatives with the patient based onthe results of the initial evaluation with no furthertesting (See Figure 1). The treatment choice is reached in a shared decision-making process be-tween the clinician and patient. If treatment is suc-cessful and the patient is satisfied, yearly follow-upwith re-evaluation will detect progressive disease. Detailed Management If the patient’s LUTS are being managed by a pri-mary care giver and the patient has persistent both-ersome LUTS after basic management, a urologistshould be consulted. The urologist may use testing beyond that recommended for basic evaluation(fig. 2). If drug therapy is considered, decisions will be influenced by coexisting overactive bladder symp-toms and prostate size or serum PSA levels (fig. 2).The decision for choice of therapy should be in con-cert with the patient’s preferences.If storage symptoms predominate, an overactivebladder due to idiopathic detrusor overactivity is themost likely cause if there is no indication of BOOfrom a flow study. The treatment options of lifestyleintervention (fluid intake alteration), behavioralmodification and pharmacotherapy (anticholinergic Figure 1.  Basic management of lower urinary tract symptoms in men 6 AUA GUIDELINE ON MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA  1795  drugs) should be discussed with the patient.  It isthe expert opinion of the Panel that some maybenefit using a combination of all three modal-ities. Should improvement be insufficient andsymptoms severe, then newer modalities canbe considered.  It is recommended that the patientbe followed to assess treatment outcome. Interventional Therapy If the patient elects interventional therapy andthere is sufficient evidence of obstruction, patientand urologist should discuss the benefits and risks of the various interventions. Transurethral resectionis still the gold standard but, when available, newtherapies could be discussed.If the patient’s condition does not suggest ob-struction (e.g., maximum flow rate   10 mL/sec)pressure flow studies are optional as treatment fail-ure rates are higher in the absence of obstruction. If therapy is planned without evidence of obstruction,the patient needs to be informed of possible higherprocedure failure rates. Treatment Alternatives The patient must be informed of all treatment alter-natives applicable to his clinical condition and therelated benefits and risks so that he may participatein decision making. The treatment choices listed inTable 1 are discussed in this article with the sup-porting evidence presented in Chapter 3 of theGuideline ( www.AUAnet.org/BPH2010 ). Standard: Information on the benefits andharms of treatment alternatives for LUTSsecondary to BPH should be explained topatients with moderate to severe symp- Figure 2.  Detailed management of persistent, bothersome lower urinary tract symptoms after basic management 6 AUA GUIDELINE ON MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA 1796

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