Management of Benign Prostatic Hyperplasia/Lower Urinary Tract Symptoms
Evaluation
Initial Evaluation
1. In the initial evaluation of patients presenting with bothersome LUTS possibly attributed to BPH, clinicians should obtain a medical history, conduct a physical examination, utilize the International Prostate Symptom Score (IPSS), and perform a urinalysis.
(Clinical Principle, )2. Patients should be counselled on options for intervention, which can include behavioral/lifestyle modifications, medical therapy and/or referral for discussion of procedural options.
(Expert Opinion, )Follow-up Evaluation
3. Patients should be evaluated by their providers 4-12 weeks after initiating treatment (provided adverse events do not require earlier consultation) to assess response to therapy. Revaluation should include the IPSS. Further evaluation may include a post-void residual (PVR) and uroflowmetry.
(Clinical Principle, )4. Patients with bothersome LUTS/BPH who elect initial medical management and do not have symptom improvement and/or experience intolerable side effects should undergo further evaluation and consideration of change in medical management or surgical intervention.
(Expert Opinion, )Preoperative Testing
5. Clinicians should consider assessment of prostate size and shape via transrectal or abdominal ultrasound, cystoscopy, or cross-sectional imaging (i.e., magnetic resonance imaging [MRI]/ computed tomography [CT]) if such studies are available, prior to intervention for LUTS/BPH.
(Clinical Principle, )6. Clinicians should perform a PVR assessment prior to intervention for LUTS/BPH.
(Clinical Principle, )7. Clinicians should consider uroflowmetry prior to intervention for LUTS/BPH.
(Clinical Principle, )8. Clinicians should consider pressure flow studies prior to intervention for LUTS/BPH when diagnostic uncertainty exists.
(Expert Opinion, )9. Clinicians should inform patients of the possibility of treatment failure and the need for additional or secondary treatments when considering surgical and minimally-invasive treatments for LUTS/BPH.
(Clinical Principle, )Medical Therapy
Alpha Blockers
10. Clinicians should offer one of the following alpha blockers as a treatment option for patients with bothersome, moderate to severe LUTS/BPH: alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin.
(Moderate, A)11. When prescribing an alpha blocker for the treatment of LUTS/BPH, the choice of alpha blocker should be based on patient age and comorbidities, and different adverse event profiles (e.g., ejaculatory dysfunction [EjD], changes in blood pressure).
(Moderate, A)Alpha Blockers and Intraoperative Floppy Iris Syndrome (IFIS)
12. When initiating alpha blocker therapy, patients with planned cataract surgery should be informed of the associated risks and be advised to discuss these risks with their ophthalmologists.
(Expert Opinion, )5- Alpha Reductase inhibitor (5-ARI)
13. For the purpose of symptom improvement, 5-ARI monotherapy should be used as a treatment option in patients with LUTS/BPH with prostatic enlargement as judged by a prostate volume of >30cc on imaging, a prostate specific antigen (PSA) >1.5ng/dL, or palpable prostate enlargement on digital rectal exam (DRE).
(Moderate, B)14. 5-ARIs alone or in combination with alpha blockers are recommended as a treatment option to prevent progression of LUTS/BPH and/or reduce the risks of urinary retention and need for future prostate-related surgery.
(Strong, A)15. Before starting a 5-ARI, clinicians should inform patients of the risks of sexual side effects, certain uncommon physical side effects, and the low risk of prostate cancer.
(Moderate, C)16. Clinicians may consider 5-ARIs as a treatment option to reduce intraoperative bleeding and peri- or postoperative need for blood transfusion after transurethral resection of the prostate (TURP) or other surgical intervention for BPH.
(Expert Opinion, )Phosphodiesterase-5 Inhibitor (PDE5)
17. For patients with LUTS/BPH irrespective of comorbid erectile dysfunction (ED), 5mg daily tadalafil should be discussed as a treatment option.
(Moderate, B)Combination Therapy
18. 5-ARI in combination with an alpha blocker should be offered as a treatment option only to patients with LUTS associated with demonstrable prostatic enlargement as judged by a prostate volume of > 30cc on imaging, a PSA >1.5ng/dL, or palpable prostate enlargement on DRE.
(Strong, A)19. Anticholinergic agents, aloneor in combination with an alpha blocker, may be offered as a treatment option to patients with moderate to severe predominant storage LUTS.
(Conditional, C)20. Beta-3-agonists in combination with an alpha blocker may be offered as a treatment option to patients with moderate to severe storage-predominant LUTS.
(Conditional, C)21. Clinicians may offer the combination of low-dose daily 5mg tadalafil with alpha blockers for the treatment of LUTS/BPH.
(Conditional, C)Acute Urinary Retention (AUR) Outcomes
23. Physicians should prescribe an oral alpha blocker prior to a voiding trial to treat patients with AUR related to BPH.
(Moderate, B)24. Patients newly treated for AUR with alpha blockers should complete at least three days of medical therapy prior to attempting trial without a catheter (TWOC).
(Expert Opinion, )25. Clinicians should inform patients who pass a successful TWOC for AUR from BPH that they remain at increased risk for recurrent urinary retention.
(Moderate, C)Surgical Therapy
26. Surgery is recommended for patients who have renal insufficiency secondary to BPH, refractory urinary retention secondary to BPH, recurrent urinary tract infections (UTIs), recurrent bladder stones or gross hematuria due to BPH, and/or with LUTS/BPH refractory to or unwilling to use other therapies.
(Clinical Principle, )27. Clinicians should not perform surgery solely for the presence of an asymptomatic bladder diverticulum. However, evaluation for the presence of bladder outlet obstruction (BOO) should be considered.
(Clinical Principle, )Transurethral Resection of the Prostate (TURP)
28. TURP should be offered as a treatment option for patients with LUTS/BPH.
(Moderate, B)29. Clinicians may use a monopolar or bipolar approach to TURP as a treatment option, depending on their expertise with these techniques.
(Expert Opinion, )30. Open, laparoscopic, or robotic assisted prostatectomy should be considered as treatment options by clinicians, depending on their expertise with these techniques, only in patients with large to very large prostates.
(Moderate, C)Transurethral Incision of the Prostate (TUIP)
31. TUIP should be offered as an option for patients with prostates ≤30cc for the surgical treatment of LUTS/BPH.
(Moderate, B)Transurethral Vaporization of the Prostate (TUVP)
32. Bipolar TUVP may be offered as an option to patients for the treatment of LUTS/BPH.
(Conditional, B)Photoselective Vaporization of the Prostate (PVP)
33. PVP should be offered as an option using 120W or 180W platforms for the treatment of LUTS/BPH.
(Moderate, B)Prostatic Urethral Lift (PUL)
34. PUL should be considered as a treatment option for patients with LUTS/BPH provided prostate volume 30-80cc and verified absence of an obstructive middle lobe.
(Moderate, C)35. PUL may be offered as a treatment option to eligible patients who desire preservation of erectile and ejaculatory function.
(Conditional, C)Transurethral Microwave Therapy (TUMT)
35. TUMT may be offered as a treatment option to patients with LUTS/BPH.
(Conditional, C)Water Vapor Thermal Therapy (WVTT)
36. WVTT should be considered as a treatment option for patients with LUTS/BPH provided prostate volume 30-80g.
(Moderate, C)37. WVTT may be offered as a treatment option to eligible patients who desire preservation of erectile and ejaculatory function.
(Conditional, C)Transurethral Needle Ablation (TUNA)
38. TUNA is not recommended for the treatment of LUTS/BPH.
(Expert Opinion, )Laser Enucleation
39. HoLEP or thulium laser enucleation of the prostate (ThuLEP) should be considered as an option, depending on the clinician’s expertise with these techniques,as prostate size-independent options for the treatment of LUTS/BPH.
(Moderate, B)Robotic Waterjet Treatment (RWT)
40. Robotic waterjet treatment (RWT) may be offered as a treatment option to patients with LUTS/BPH provided prostate volume 30-80cc.
(Conditional, C)Prostate Artery Embolization (PAE)
40. PAE may be offered for the treatment of LUTS/BPH. PAE should be performed by clinicians trained in this interventional radiology procedure following a discussion of the potential risks and benefits.
(Conditional, C)Hematuria
42. After exclusion of other causes of hematuria, 5-ARIs may be an appropriate and effective treatment alternative in men with refractory hematuria presumably due to prostatic bleeding.
(Expert Opinion, )Temporary Implanted Prostatic Devices (TIPD)
Medically Complicated Patients
43. HoLEP, PVP, and ThuLEP should be considered as treatment options in patients who are at higher risk of bleeding.
(Expert Opinion, )Recommendation Grading
Overview
Title
Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia (BPH)
Authoring Organization
American Urological Association
Publication Month/Year
September 14, 2023
Last Updated Month/Year
December 13, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
The purpose of this American Urological Association (AUA)Guideline amendment is to provide a useful reference on the effective evidence-based management of male lower urinary tract symptoms secondary/attributed to BPH (LUTS/BPH). This guideline seeks to improve clinicians’ ability to evaluate and treat patients with BPH/LUTSbased on currently available evidence. Future studies will be essential to further support these statements toimprovepatient care.
Inclusion Criteria
Male, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Treatment, Management
Diseases/Conditions (MeSH)
D059411 - Lower Urinary Tract Symptoms, D011470 - Prostatic Hyperplasia
Keywords
Benign Prostatic Hyperplasia, Lower Urinary Tract, Clinical guidelines, Alpha Blockers
Source Citation
Sandhu JS, Bixler BR, Dahm P, Goueli R, Kirkby E, Stoffel JT, Wilt TJ. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia (BPH): AUA Guideline Amendment 2023. J Urol. 2023 Sep 14:101097JU0000000000003698. doi: 10.1097/JU.0000000000003698. Epub ahead of print. PMID: 37706750.