Bedfrdshire and Hertfrdshire DRAFT Pririties frum statement Number: Subject: Prstatism Date f decisin: January 2010 Date f review: Referral criteria Mst men with lwer urinary tract symptms due t benign prstatic hyperplasia can be managed in primary care withut referral. Refer the man t hspital immediately (t be seen that day) if he develps acute renal failure r retentin. Urgently refer (maximum delay f 2 weeks is recmmended) men with: A hard, irregular prstate typical f prstate cancer. Prstate-specific antigen (PSA 1 ) shuld be measured and the result shuld accmpany the referral. A nrmal prstate, but rising r elevated age-specific PSA (if the man has ther cmrbidities, a discussin with him r his carers, r a specialist, may be mre apprpriate). Haematuria. Chrnic urinary retentin with verflw r night-time incntinence. Refer the man, t be seen within an apprpriate time (depending n the circumstances), if: The symptms have failed t respnd t treatment in primary care and are severe enugh t affect quality f life as measured by an IPSS scre f at least 8 (fr IPSS scre, see appendix). There is evidence f chrnic renal failure r renal damage. There are atypical symptms and a diagnsis is difficult t establish. Fr all referrals, evidence that the patient meets the abve criteria shuld be dcumented n the referral letter. 1 Serum PSA threshld levels fr referral: Age 50-59 3.0 nangrams/ml Age 60-69 4.0 nangrams/ml Age 70 years r mre 5.0 nangrams/ml
Primary Care Management f benign prstatic hyperplasia Assessment After making a clinical diagnsis f lwer urinary tract symptms secndary t benign prstatic hyperplasia, an assessment f the size f the prstate and hw bthersme urinary symptms are will influence the decisin n what treatment is ffered. Ask the man why he has cnsulted. Anxiety regarding prstate cancer may be the main reasn. Assess the severity f urinary symptms ver the last mnth, ideally using a validated scring system such as the Internatinal Prstate Severity Scre (IPSS). Ask him if his urinary symptms are trubling him and ask him t cmplete the IPSS quality f life questin. Cnsider asking him t keep a viding diary r frequency/vlume chart fr 1 2 weeks t use in interpreting symptms, especially if ncturia is a dminant symptm. Assess fr factrs that may aggravate urinary symptms, such as drugs, alchl and caffeine cnsumptin, and cnstipatin. Ask abut the presence f sexual prblems benign prstatic hyperplasia is ften assciated with sexual dysfunctin. Assess the size f the prstate: Smaller prstates are defined as being less than 30 g, and larger prstates as greater than 30 g. Hwever, accurately assessing the size f the prstate in primary care is difficult. A digital rectal examinatin may give an indicatin f the size f the prstate, but this is very subjective. Fllwing a digital rectal examinatin, if there is still uncertainty abut the size f the prstate, a prstate-specific antigen (PSA) level can act as a prxy fr prstate size. A PSA level greater than 1.4 nangrams/ml indicates a largersized prstate and an increased risk f prgressin. Hwever, PSA testing is nt rutinely recmmended and shuld nly be ffered after discussing its rle, particularly in the detectin f prstate cancer. If it is imprtant that prstate size be measured accurately, then a specialist assessment in secndary care is required.
Cnsider referring fr measurement f residual vlume if the man has predminant, trublesme strage symptms (if residual vlume is lw, an antimuscarinic drug fr the treatment f bladder ver activity might be wrth cnsidering). Infrmatin, advice and reassurance t help cpe with lwer urinary tract symptms Give reassurance that: Men with lwer urinary tract symptms are at n greater risk f prstate cancer than asymptmatic men f the same age. Urinary symptms d nt prgress in everyne, and serius cmplicatins are unlikely t ccur. T help him cpe with the symptms, advise the man t: Anticipate times when urinary frequency and urgency are likely t be mst incnvenient (e.g. at night, when ging ut), and reduce fluid intake befrehand. Hwever, ttal daily fluid intake (abut 1.5 litres) shuld nt be reduced. Reduce r avid cnsumptin f caffeine and alchl, which can aggravate frequency, urgency, and ncturia. Relax when urinating. Vid twice t ensure that the bladder is emptied as cmpletely as pssible. Cntrl urgency by practising distractin techniques, such as breathing exercises and mental tricks t take the mind ff the bladder. T prevent aggravating urinary symptms, advise the man t: Avid using drugs with antimuscarinic r sedating adverse effects (e.g. cld and flu remedies, sedating antihistamines). Avid cnstipatin Treatments if symptms are nt bthersme Fr smaller prstates, advise a trial f watchful waiting and reassess annually. Fr larger prstates, the ptins are: Watchful waiting. Prescribing a 5-alpha reductase inhibitr (finasteride r dutasteride) t reduce the risk f prgressin.
Explain that prgressin is mre likely t ccur with larger prstates, but that in mst men this will simply be an increase in symptms, with much smaller numbers develping prblems such as acute urinary retentin r a need fr prstate surgery. Taking a 5-alpha reductase inhibitr may reduce this risk, but this has t be balanced against the disadvantages f taking lng-term medicatin. If a 5-alpha reductase inhibitr is prescribed: Treatment is usually cntinued lng term r indefinitely. Review 3 6 mnths after starting treatment and then at least nce yearly thereafter. Advise against the use f herbal remedies. Treatments fr men with symptms that are bthersme Fr smaller prstates: Prescribe an alpha-blcker (e.g. alfuzsin, dxazsin, tamsulsin, r terazsin). Symptms usually imprve within several days. Cnsider fllw-up 2 3 weeks after starting treatment. Sme alpha-blckers are titrated up accrding t respnse ver a number f weeks. Other alpha-blckers (e.g. tamsulsin) d nt require titratin. Fr larger prstates: Cnsider starting treatment with an alpha-blcker and a 5-alpha reductase inhibitr (dutasteride r finasteride). Alpha-blckers usually imprve symptms within several days, with full respnse after 4 6 weeks, whereas 5-alpha reductase inhibitr imprve symptms after 3 6 mnths. Fllw up 2 3 weeks after starting treatment, at 6 mnths, and annually thereafter. Advise against the use f herbal remedies.
Appendix: Internatinal prstate symptm scre (IPSS) Frm Name: Date: Incmplete emptying Over the past mnth, hw ften have yu had a sensatin f nt emptying yur bladder cmpletely after yu finish urinating? Frequency Over the past mnth, hw ften have yu had t urinate again less than tw hurs after yu finished urinating? Intermittency Over the past mnth, hw ften have yu fund yu stpped and started again several times when yu urinated? Urgency Over the last mnth, hw difficult have yu fund it t pstpne urinatin? Weak stream Over the past mnth, hw ften have yu had a weak urinary stream? Straining Over the past mnth, hw ften have yu had t push r strain t begin urinatin? Nt at all Less than 1 time in 5 Less than half the time Abut half the time Mre than half the time Almst always Yur scre Ncturia Over the past mnth, many times did yu mst typically get up t urinate frm the time yu went t bed until the time yu gt up in the mrning? Nne 1 time 2 times 3 times 4 times 5 times r mre Yur scre Ttal IPSS scre Quality f life due t urinary symptms If yu were t spend the rest f yur life with yur urinary cnditin the way it is nw, hw wuld yu feel abut that? Delighted Pleased Mstly satisfied Mixed abut equally satisfied and dissatisfied Mstly dissatisfied Unhappy 6 Terrible Ttal scre: 0-7 Mildly symptmatic; 8-19 mderately symptmatic; 20-35 severely symptmatic. The Human Rights Act has been cnsidered in the frmatin f this guidance statement.