AUA Updates LUTS/BPH Guidelines on Initial Workup, Surgery

Marcia Frellick

September 01, 2021

The American Urological Association (AUA) has updated its guidelines on managing male lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia (BPH).

The updates, the first since 2010, were summarized in the Journal of Urology in two parts. Part I concerns initial workup and medical management; part II focuses on surgical evaluation and treatment.

Dr Lori Lerner

Lori B. Lerner, MD, with the Department of Surgery, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, will present the guidelines in a plenary session of the American Urological Association (AUA) 2021 Annual Meeting on September 13.

"In many cases, the messaging is the same and consistent," Lerner told Medscape Medical News. "However, as some treatments have fallen out of favor and new ones have become utilized, it was essential to review the trends and outcomes over the last decade to inform current approaches and treatment strategies."

In part I ― initial workup and management ― the guidelines committee advises practitioners to use the International Prostate Symptoms Score (IPSS) at each visit, with appropriate follow-up once therapy has been initiated.

"When available, tools such as a post-void residual urine volume and urine flow rate test can help determine success or failure of initial therapy and indicate the need to move on to other therapeutic options. Urinary retention should be addressed with alpha blockers at initial evaluation, with failure to void indicating a need for further workup and potentially more invasive interventions," she said.

Guidelines Address Beta 3 Agonists

Lerner said this version of the guidelines includes updated information regarding the use of beta 3 agonists and phosphodiesterase-5 (PDE5) inhibitors in the treatment of symptomatic LUTS attributed to BPH.

Prior guidelines did not include beta 3 agonists, a relatively new class of medication used to treat overactive bladder, which can occur secondary to obstruction from BPH.

The current guidelines support use of beta 3 agonists in combination with an alpha blocker for patients with moderate to severe predominate storage LUTS. This was assigned a grade C level of evidence and is a conditional recommendation.

The 2010 guidelines introduced the use of PDE5s, but at that time, the data were not robust enough to support a statement, Lerner said.

Updated information on PDE5s indicates that for patients with LUTS/BPH, irrespective of comorbid erectile dysfunction, tadalafil (Cialis) 5 mg daily should be discussed as a treatment option. Results of key trials suggest that tadalafil probably increases response to the IPSS compared with placebo, as determined on the basis of the percentage of patients whose condition responded to treatment (defined as a change in IPSS of ≥3 points). That was a moderate recommendation, with an evidence level of grade B.

Alpha blocker therapy and 5-alpha-reductase inhibitors (5-ARIs) remain the primary medical treatment, Lerner said.

"However, 5-ARIs have come under scrutiny, given recent publications regarding post-finasteride syndrome, which is discussed in the full guidelines document," she said.

The authors also reviewed data on popular natural therapies that are purported to have benefits for patients with BPH.

Many supplements and nutraceuticals contain ingredients such as saw palmetto, Pygeum africanum, stinging nettle, zinc, selenium, and others.

Results have been variable, the authors note, as have study methods and quality, so the committee writes that it can't recommend them.

Surgical Interventions

Part II of the guidelines concern surgical interventions. The committee addresses new techniques in robotic and laparoscopic simple prostatectomy, prostatic urethral lift, water vapor thermal therapy, robotic water jet therapy, and prostatic arterial embolization.

"Transurethral nuclear ablation has fallen out of favor, and given its relatively limited application with no new data, this therapy is no longer recommended," Lerner said.

The committee this year highlighted re-treatment rates.

"Traditional trials have been inconsistent with reporting regarding re-treatment, and this has not been considered an essential element. Therefore, reported rates are variable and incomplete. The committee feels strongly that this discussion is vitally important in the field of BPH, and as such, data that could be acquired were reviewed and included," Lerner said.

In addition, the guideline introduces the possibility of procedural intervention, rather than medical therapy, as a primary approach, Lerner said. "For some patients, after an informed discussion between the patient and provider is conducted, avoiding medication is a reasonable strategy," she said.

The incidence of BPH begins to increase in patients aged 40 to 45 years, the authors write. The incidence is 60% by age 60 and 80% by age 80. LUTS also increases in frequency and severity with age.

There are many unanswered questions regarding BPH; the "future directions" segment of the guidelines highlights areas of unmet need.

Lerner said she hopes future iterations not only will include new medical and surgical therapies but will also help answer questions regarding timing of intervention and better understanding of the pathologic and physiologic changes, as well as more streamlined therapeutic strategies.

Authors report no relevant financial relationships.

J Urol. Published online August 13, 2021.Part I, Abstract; Part II, Abstract

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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