- •Preface and Acknowledgments
- •Contents
- •Contributors
- •1: Embryology for Urologists
- •Introduction
- •Renal Development
- •Pronephros
- •Mesonephros
- •Metanephros
- •Development of the Collecting System
- •Critical Steps in Further Development
- •Anomalies of the Kidney
- •Renal Agenesis
- •Renal Aplasia
- •Renal Hypoplasia
- •Renal Ectopia
- •Renal Fusion
- •Ureteral Development
- •Anomalies of Origin
- •Anomalies of Number
- •Incomplete Ureteral Duplication
- •Complete Ureteral Duplication
- •Ureteral Ectopia
- •Embryology of Ectopia
- •Clinical Correlation
- •Location of Ectopic Ureteral Orifices – Male (in Descending Order According to Incidence)
- •Symptoms
- •Ureteroceles
- •Congenital Ureteral Obstruction
- •Pipestem Ureter
- •Megaureter-Megacystis Syndrome
- •Prune Belly Syndrome
- •Vascular Ureteral Obstructions
- •Division of the Urogenital Sinus
- •Bladder Development
- •Urachal Anomalies
- •Cloacal Duct Anomalies
- •Other Bladder Anomalies
- •Bladder Diverticula
- •Bladder Extrophy
- •Gonadal Development
- •Testicular Differentiation
- •Ovarian Differentiation
- •Gonadal Anomalies
- •Genital Duct System
- •Disorders of Testicular Function
- •Female Ductal Development
- •Prostatic Urethral Valves
- •Gonadal Duct Anomalies
- •External Genital Development
- •Male External Genital Development
- •Female External Genital Development
- •Anomalies of the External Genitalia
- •References
- •2: Gross and Laparoscopic Anatomy of the Upper Urinary Tract and Retroperitoneum
- •Overview
- •The Kidneys
- •The Renal Vasculature
- •The Renal Collecting System
- •The Ureters
- •Retroperitoneal Lymphatics
- •Retroperitoneal Nerves
- •The Adrenal Glands
- •References
- •3: Gross and Laparoscopic Anatomy of the Lower Urinary Tract and Pelvis
- •Introduction
- •Female Pelvis
- •Male Pelvis
- •Pelvic Floor
- •Urinary Bladder
- •Urethra
- •Male Urethra
- •Female Urethra
- •Sphincter Mechanisms
- •The Bladder Neck Component
- •The Urethral Wall Component
- •The External Urethral Sphincter
- •Summary
- •References
- •4: Anatomy of the Male Reproductive System
- •Testis and Scrotum
- •Spermatogenesis
- •Hormonal Regulation of Spermatogenesis
- •Genetic Regulation of Spermatogenesis
- •Epididymis and Ductus Deferens
- •Accessory Sex Glands
- •Prostate
- •Seminal Vesicles
- •Bulbourethral Glands
- •Penis
- •Erection and Ejaculation
- •References
- •5: Imaging of the Upper Tracts
- •Anatomy of the Upper Tracts and Introduction to Imaging Modalities
- •Introduction
- •Renal Upper Tract Basic Anatomy
- •Modalities Used for Imaging the Upper Tracts
- •Ultrasound
- •Radiation Issues
- •Contrast Issues
- •Renal and Upper Tract Tumors
- •Benign Renal Tumors
- •Transitional Cell Carcinoma
- •Renal Mass Biopsy
- •Renal Stone Disease
- •Ultrasound
- •Plain Radiographs and IVU
- •Renal Cystic Disease
- •Benign Renal Cysts
- •Hereditary Renal Cystic Disease
- •Complex Renal Cysts
- •Renal Trauma
- •References
- •Introduction
- •Pathophysiology
- •Susceptibility and Resistance
- •Epidemiological Breakpoints
- •Clinical Breakpoints
- •Pharmacodynamic Parameters
- •Pharmacokinetic Parameters
- •Fosfomycin
- •Nitrofurantoin
- •Pivmecillinam
- •b-Lactam-Antibiotics
- •Penicillins
- •Cephalosporins
- •Carbapenems
- •Aminoglycosides
- •Fluoroquinolones
- •Trimethoprim, Cotrimoxazole
- •Glycopeptides
- •Linezolid
- •Conclusion
- •References
- •7: An Overview of Renal Physiology
- •Introduction
- •Body Fluid Compartments
- •Regulation of Potassium Balance
- •Regulation of Acid–Base Balance
- •Diuretics
- •Suggested Reading
- •8: Ureteral Physiology and Pharmacology
- •Ureteral Anatomy
- •Modulation of Peristalsis
- •Ureteral Pharmacology
- •Conclusion
- •References
- •Introduction
- •Afferent Signaling Pathways
- •Efferent Signaling
- •Parasympathetic Nerves
- •Sympathetic Nerves
- •Vesico-Spinal-Vesical Micturition Reflex
- •Peripheral Targets
- •Afferent Signaling Mechanisms
- •Urothelium
- •Myocytes
- •Cholinergic Receptors
- •Muscarinic Receptors
- •Nicotinic Receptors
- •Adrenergic Receptors (ARs)
- •a-Adrenoceptors
- •b-Adrenoceptors
- •Transient Receptor Potential (TRP) Receptors
- •Phosphodiesterases (PDEs)
- •CNS Targets
- •Opioid Receptors
- •Serotonin (5-HT) Mechanisms
- •g-Amino Butyric Acid (GABA) Mechanisms
- •Gabapentin
- •Neurokinin and Neurokinin Receptors
- •Summary
- •References
- •10: Pharmacology of Sexual Function
- •Introduction
- •Sexual Desire/Arousal
- •Endocrinology
- •Steroids in the Male
- •Steroids in the Female
- •Neurohormones
- •Neurotransmitters
- •Dopamine
- •Serotonin
- •Pharmacological Strategies
- •CNS Drugs
- •Enzyme-inducing Antiepileptic Drugs
- •Erectile Function
- •Ejaculatory Function
- •Premature Ejaculation
- •Abnormal Ejaculation
- •Conclusions
- •References
- •Epidemiology
- •Calcium-Based Urolithiasis
- •Uric Acid Urolithiasis
- •Infectious Urolithiasis
- •Cystine-Based Urolithiasis
- •Aims
- •Who Deserves Metabolic Evaluation?
- •Metabolic Workup for Stone Producers
- •Medical History and Physical Examination
- •Stone Analysis
- •Serum Chemistry
- •Urine Evaluation
- •Urine Cultures
- •Urinalysis
- •Twenty-Four Hour Urine Collections
- •Radiologic Imaging
- •Medical Management
- •Conservative Management
- •Increased Fluid Intake
- •Citrus Juices
- •Dietary Restrictions
- •Restricted Oxalate Diet
- •Conservative Measures
- •Selective Medical Therapy
- •Absorptive Hypercalciuria
- •Thiazide
- •Orthophosphate
- •Renal Hypercalciuria
- •Primary Hyperparathyroidism
- •Hyperuricosuric Calcium Oxalate Nephrolithiasis
- •Enteric Hyperoxaluria
- •Hypocitraturic Calcium Oxalate Nephrolithiasis
- •Distal Renal Tubular Acidosis
- •Chronic Diarrheal States
- •Thiazide-Induced Hypocitraturia
- •Idiopathic Hypocitraturic Calcium Oxalate Nephrolithiasis
- •Hypomagnesiuric Calcium Nephrolithiasis
- •Gouty Diathesis
- •Cystinuria
- •Infection Lithiasis
- •Summary
- •References
- •12: Molecular Biology for Urologists
- •Introduction
- •Inherited Changes in Cancer Cells
- •VEGR and Cell Signaling
- •Targeting mTOR
- •Conclusion
- •References
- •13: Chemotherapeutic Agents for Urologic Oncology
- •Introduction
- •Bladder Cancer
- •Muscle Invasive Bladder Cancer
- •Metastatic Bladder Cancer
- •Conclusion
- •Prostate Cancer
- •Other Chemotherapeutic Drugs or Combinations for Treating HRPC
- •Conclusion
- •Renal Cell Carcinoma
- •Chemotherapy
- •Immunotherapy
- •Angiogenesis Inhibitor Drugs
- •Conclusion
- •Testicular Cancer
- •Stage I Seminoma
- •Stage I non-seminomatous Germ Cell Tumours (NSGCT)
- •Metastatic Germ Cell Tumours
- •Low-Volume Metastatic Disease (Stage II A/B)
- •Advanced Metastatic Disease
- •Salvage Chemotherapy for Relapsed or Refractory Disease
- •Conclusion
- •Penile Cancer
- •Side Effects of Chemotherapy
- •Conclusion
- •References
- •14: Tumor and Transplant Immunology
- •Antibodies
- •Cytotoxic and T-helper Cells
- •Immunosuppression
- •Induction Therapy
- •Maintenance Therapy
- •Rejection
- •Posttransplant Lymphoproliferative Disease
- •Summary
- •References
- •15: Pathophysiology of Renal Obstruction
- •Causes of Renal Obstruction
- •Effects on Prenatal Development
- •Prenatal Hydronephrosis
- •Spectrum of Renal Abnormalities
- •Renal Functional Changes
- •Renal Growth/Counterbalance
- •Vascular Changes
- •Inflammatory Mediators
- •Glomerular Development Changes
- •Mechanical Stretch of Renal Tubules
- •Unilateral Versus Bilateral
- •Limitations of Animal Models
- •Future Research
- •Issues in Patient Management
- •Diagnostic Imaging
- •Ultrasound
- •Intravenous Urography
- •Antegrade Urography and the Whitaker Test
- •Nuclear Renography
- •Computed Tomography
- •Magnetic Resonance Urography
- •Hypertension
- •Postobstructive Diuresis
- •References
- •Introduction
- •The Normal Lower Urinary Tract
- •Anatomy
- •Storage Function
- •Voiding Function
- •Neural Control
- •Symptoms
- •Flow Rate and Post-void Residual
- •Voiding Cystometry
- •Male
- •Female
- •Neurourology
- •Conclusions
- •References
- •17: Urologic Endocrinology
- •The Testis
- •Normal Androgen Metabolism
- •Epidemiological Aspects
- •Prostate
- •Brain
- •Muscle Mass and Adipose Tissue
- •Bones
- •Ematopoiesis
- •Metabolism
- •Cardiovascular System
- •Clinical Assessment
- •Biochemical Assessment
- •Treatment Modalities
- •Oral Preparations
- •Parenteral Preparations
- •Transdermal Preparations
- •Side Effects and Treatment Monitoring
- •Body Composition
- •Cognitive Decline
- •Bone Metabolism
- •The Kidneys
- •Endocrine Functions of the Kidney
- •Erythropoietin
- •Calcitriol
- •Renin
- •Paraneoplastic Syndromes
- •Hypercalcemia
- •Hypertension
- •Polycythemia
- •Other Endocrine Abnormalities
- •References
- •General Physiology
- •Prostate Innervation
- •Summary
- •References
- •Wound Healing
- •Inflammation
- •Proliferation
- •Remodeling
- •Principles of Plastic Surgery
- •Tissue Characteristics
- •Grafts
- •Flap
- •References
- •Lower Urinary Tract Symptoms
- •Storage Phase
- •Voiding Phase
- •Return to Storage Phase
- •Urodynamic Parameters
- •Urodynamic Techniques
- •Volume Voided Charts
- •Pad Testing
- •Typical Test Schedule
- •Uroflowmetry
- •Post Voiding Residual
- •Further Diagnostic Evaluation of Patients
- •Cystometry with or Without Video
- •Cystometry
- •Videocystometrography (Cystometry + Cystourethrography)
- •Cystometric Findings
- •Comment:
- •Measurements During the Storage Phase:
- •Measurements During the Voiding Phase:
- •Abnormal Function
- •Disorders of Sensation
- •Causes of Hypersensitive Bladder Sensation
- •Causes of Hyposensitive Bladder Sensation
- •Disorders of Detrusor Motor Function
- •Bladder Outflow Tract Dysfunction
- •Detrusor–Urethral Dyssynergia
- •Detrusor–Bladder Neck Dyssynergia
- •Detrusor–Sphincter Dyssynergia
- •Complex Urodynamic Investigation
- •Urethral Pressure Measurement
- •Technique
- •Neurophysiological Evaluation
- •Conclusion
- •References
- •Endoscopy
- •Cystourethroscopy
- •Ureteroscopy and Ureteropyeloscopy
- •Nephroscopy
- •Virtual Reality Simulators
- •Lasers
- •Clinical Application of Lasers
- •Condylomata Acuminata
- •Urolithiasis
- •Benign Prostatic Hyperplasia
- •Ureteral and Urethral Strictures
- •Conclusion
- •References
- •Introduction
- •The Prostatitis Syndromes
- •The Scope of the Problem
- •Category III CP/CPPS
- •The Goal of Treatment
- •Conservative Management
- •Drug Therapy
- •Antibiotics
- •Anti-inflammatories
- •Alpha blockers
- •Hormone Therapies
- •Phytotherapies
- •Analgesics, muscle relaxants and neuromodulators
- •Surgery
- •A Practical Management Plan
- •References
- •Orchitis
- •Definition and Etiology
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation
- •Treatment of Infectious Orchitis
- •Epididymitis
- •Definition and Etiology
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation of Epididymitis
- •Treatment of Acute Epididymitis
- •Treatment of Chronic Epididymitis
- •Treatment of Spermatic Cord Torsion
- •Fournier’s Gangrene
- •Definition and Etiology
- •Risk Factors
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation
- •Treatment
- •References
- •Fungal Infections
- •Candidiasis
- •Aspergillosis
- •Cryptococcosis
- •Blastomycosis
- •Coccidioidomycosis
- •Histoplasmosis
- •Radiographic Findings
- •Treatment
- •Tuberculosis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Schistosomiasis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Filariasis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Onchocerciasis
- •References
- •25: Sexually Transmitted Infections
- •Introduction
- •STIs Associated with Genital Ulcers
- •Herpes Simplex Virus
- •Diagnosis
- •Treatment
- •Chancroid
- •Diagnosis
- •Treatment
- •Syphilis
- •Diagnosis
- •Treatment
- •Lymphogranuloma Venereum
- •Diagnosis
- •Treatment
- •Chlamydia
- •Diagnosis
- •Treatment
- •Gonorrhea
- •Diagnosis
- •Treatment
- •Trichomoniasis
- •Diagnosis
- •Treatment
- •Human Papilloma Virus
- •Diagnosis
- •Treatment
- •Scabies
- •Diagnosis
- •Treatment
- •References
- •26: Hematuria: Evaluation and Management
- •Introduction
- •Classification of Hematuria
- •Macroscopic Hematuria
- •Microscopic Hematuria
- •Dipstick Hematuria
- •Pseudohematuria
- •Factitious Hematuria
- •Menstruation
- •Aetiology
- •Malignancy
- •Urinary Calculi
- •Infection and Inflammation
- •Benign Prostatic Hyperplasia
- •Trauma
- •Drugs
- •Nephrological Causes
- •Assessment
- •History
- •Examination
- •Investigations
- •Dipstick Urinalysis
- •Cytology
- •Molecular Tests
- •Blood Tests
- •Flexible Cystoscopy
- •Upper Urinary Tract Evaluation
- •Renal USS
- •KUB Abdominal X-Ray
- •Intravenous Urography (IVU)
- •Computed Tomography (CT)
- •Retrograde Urogram Studies
- •Magnetic Resonance Imaging (MRI)
- •Additional Tests and Renal Biopsy
- •Intractable Hematuria
- •Loin Pain Hematuria Syndrome
- •References
- •27: Benign Prostatic Hyperplasia (BPH)
- •Historical Background
- •Pathophysiology
- •Patient Assessment
- •Treatment of BPH
- •Watchful Waiting
- •Drug Therapy
- •Interventional Therapies
- •Conclusions
- •References
- •28: Practical Guidelines for the Treatment of Erectile Dysfunction and Peyronie´s Disease
- •Erectile Dysfunction
- •Introduction
- •Diagnosis
- •Basic Evaluation
- •Cardiovascular System and Sexual Activity
- •Optional Tests
- •Treatment
- •Medical Treatment
- •Oral Agents
- •Phosphodiesterase Type 5 (PDE 5) Inhibitors
- •Nonresponders to PDE5 Inhibitors
- •Apomorphine SL
- •Yohimbine
- •Intracavernosal and Intraurethral Therapy
- •Intracavernosal Injection (ICI) Therapy
- •Intraurethral Therapy
- •Vacuum Constriction Devices
- •Surgical Therapy
- •Conclusion
- •Peyronie´s Disease (PD)
- •Introduction
- •Oral Drug Therapy
- •Intralesional Drug Therapy
- •Iontophoresis
- •Radiation Therapy
- •Surgical Therapy
- •References
- •29: Premature Ejaculation
- •Introduction
- •Epidemiology
- •Defining Premature Ejaculation
- •Voluntary Control
- •Sexual Satisfaction
- •Distress
- •Psychosexual Counseling
- •Pharmacological Treatment
- •On-Demand Treatment with Tramadol
- •Topical Anesthetics
- •Phosphodiesterase Inhibitors
- •Surgery
- •Conclusion
- •References
- •30: The Role of Interventional Management for Urinary Tract Calculi
- •Contraindications to ESWL
- •Complications of ESWL
- •PCNL Access
- •Instrumentation for PCNL
- •Nephrostomy Drains Post PCNL
- •Contraindications to PCNL
- •Complications of PCNL
- •Semirigid Ureteroscopy
- •Flexible Ureteroscopy
- •Electrohydraulic Lithotripsy (EHL)
- •Ultrasound
- •Ballistic Lithotripsy
- •Laser Lithotripsy
- •Ureteric Stents
- •Staghorn Calculi
- •Lower Pole Stones
- •Horseshoe Kidneys and Stones
- •Calyceal Diverticula Stones
- •Stones and PUJ Obstruction
- •Treatment of Ureteric Colic
- •Medical Expulsive Therapy (MET)
- •Intervention for Ureteric Stones
- •Stones in Pregnancy
- •Morbid Obesity
- •References
- •Anatomy and Function
- •Pathophysiology
- •Management
- •Optical Urethrotomy/Dilatation
- •Urethral Stents
- •Preoperative Assessment
- •Urethroplasty
- •Anastomotic Urethroplasty
- •Substitution Urethroplasty
- •Grafts Versus Flaps
- •Oral Mucosal Grafts
- •Tissue Engineering
- •Graft Position
- •Conclusion
- •References
- •32: Urinary Incontinence
- •Epidemiology and Risk Factors
- •Pathophysiology
- •Urge Incontinence
- •Conservative Treatments
- •Pharmacotherapy
- •Invasive/ Surgical Therapies
- •Stress Urinary Incontinence
- •Male SUI Therapies
- •Female SUI Therapies
- •Mixed Urinary Incontinence
- •Conclusions
- •References
- •33: Neurogenic Bladder
- •Introduction
- •Examination and Diagnostic Tests
- •History and Physical Examination
- •Imaging
- •Urodynamics (UDS)
- •Evoked Potentials
- •Classifications
- •Somatic Pathways
- •Brain Lesions
- •Cerebrovascular Accident (CVA)
- •Parkinson’s Disease (PD)
- •Multiple Sclerosis
- •Huntington’s Disease
- •Dementias
- •Normal Pressure Hydrocephalus (NPH)
- •Tumors
- •Psychiatric Disorders
- •Spinal Lesions and Pathology
- •Intervertebral Disk Prolapse
- •Spinal Cord Injury (SCI)
- •Transverse Myelitis
- •Peripheral Neuropathies
- •Metabolic Neuropathies
- •Pelvic Surgery
- •Treatment
- •Summary
- •References
- •34: Pelvic Prolapse
- •Introduction
- •Epidemiology
- •Anatomy and Pathophysiology
- •Evaluation and Diagnosis
- •Outcome Measures
- •Imaging
- •Urodynamics
- •Indications for Management
- •Biosynthetics
- •Surgical Management
- •Anterior Compartment Repair
- •Uterine/Apical Prolapse
- •Enterocele Repair
- •Conclusion
- •References
- •35: Urinary Tract Fistula
- •Introduction
- •Urogynecologic Fistula
- •Vesicovaginal Fistula
- •Etiology and Risk Factors
- •Clinical Factors
- •Evaluation and Diagnosis
- •Pelvic Examination
- •Cystoscopy
- •Imaging
- •Treatment
- •Conservative Management
- •Surgical Management
- •Urethrovaginal Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Ureterovaginal Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Vesicouterine Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Uro-Enteric Fistula
- •Vesicoenteric Fistula
- •Pyeloenteric Fistula
- •Urethrorectal Fistula
- •References
- •36: Urologic Trauma
- •Introduction
- •Kidney
- •Expectant Management
- •Endovascular Therapy
- •Operative Intervention
- •Operative Management: Follow-up
- •Reno-Vascular Injuries
- •Pediatric Renal Injuries
- •Adrenal
- •Ureter
- •Diagnosis
- •Treatment
- •Delayed Diagnosis
- •Bladder and Posterior Urethra
- •Bladder Injuries: Initial Management
- •Bladder Injuries: Formal Repair
- •Anterior Urethral Trauma
- •Fractured Penis
- •Penile Amputation
- •Scrotal and Testicular Trauma
- •Imaging
- •CT-IVP (CT with Delayed Images)
- •Technique
- •Cystogram
- •Technique
- •Retrograde Urethrogram (RUG)
- •Technique
- •Retrograde Pyelogram (RPG)
- •Technique
- •One-Shot IVP
- •Technique
- •References
- •37: Bladder Cancer
- •Who Should Be Investigated?
- •Epidemiology
- •Risk Factors
- •Role of Screening
- •Signs and Symptoms
- •Imaging
- •Cystoscopy
- •Urine Tests
- •PDD-Assisted TUR
- •Pathology
- •NMIBC and Risk Groups
- •Intravesical Chemotherapy
- •Intravesical Immunotherapy
- •Immediate Cystectomy and CIS
- •Radical Cystectomy with Pelvic Lymph Node Dissection
- •sexual function-preserving techniques
- •Bladder-Preservation Treatments
- •Neoadjuvant Chemotherapy
- •Adjuvant Chemotherapy
- •Preoperative Radiotherapy
- •Follow-up After TUR in NMIBC
- •References
- •38: Prostate Cancer
- •Introduction
- •Epidemiology
- •Race
- •Geographic Variation
- •Risk Factors and Prevention
- •Family History
- •Diet and Lifestyle
- •Prevention
- •Screening and Diagnosis
- •Current Screening Recommendations
- •Biopsy
- •Pathology
- •Prognosis
- •Treatment of Prostate Cancer
- •Treatment for Localized Prostate Cancer (T1, T2)
- •Radical Prostatectomy
- •EBRT
- •IMRT
- •Brachytherapy
- •Treatment for Locally Advanced Prostate Cancer (T3, T4)
- •EBRT with ADT
- •Radical Prostatectomy
- •Androgen-Deprivation Therapy
- •Summary
- •References
- •39: The Management of Testis Cancer
- •Presentation and Diagnosis
- •Serum Tumor Markers
- •Primary Surgery
- •Testis Preserving Surgery
- •Risk Stratification
- •Surveillance Versus Primary RPLND
- •Primary RPLND
- •Adjuvant Treatment for High Risk
- •Clinical Stage 1 Seminoma
- •Risk-Stratified Adjuvant Treatment
- •Adjuvant Radiotherapy
- •Adjuvant Low Dose Chemotherapy
- •Primary Combination Chemotherapy
- •Late Toxicity
- •Salvage Strategies
- •Conclusion
- •References
- •Index
27
Benign Prostatic Hyperplasia (BPH)
Andrea Tubaro and Cosimo de Nunzio
Historical Background
The first description of the prostate gland goes back to Andreas Vesalius in his book entitled Tabulae anatomicae (1538). In 1564, Ambroise Paré, the Renaissance master of French surgery, described obstructive urinary symptoms. Two centuries later, in 1786, John Hunter, the famous British surgeon, related prostatic enlargement to obstructive symptoms, detrusor hypertrophy, and upper urinary tract dilatation.Transurethral instruments to relieve prostatic obstruction were first developed by Jean Civiale in Paris and Enrico Bottini. Eugene Fuller (1858–1930) and Peter Fryer (1852–1921) in Britain and George Goodfellow (1855–1910) in the United States pioneered surgery of BPH. In the twentieth century, new surgical techniques were developed thanks to people like Terence Millin, Hugh H. Young, James Buchanan Brady, George Luys, Maximilian Stern,Joseph McCarthy,and Frederic Foley.1
Epidemiology and Natural
History
Epidemiology research strictly depends upon the definition of the disease/condition and BPH is not without problem as there is no consensus on a unique definition.2 Current terminology, as revised by Abrams et al. in 2002, describe the objective finding of a Benign Prostatic
Enlargement (BPE), a histological diagnosis (Benign Prostatic Hyperplasia – BPH) and the obstruction that can derive from BPH (Benign Prostatic Obstruction – BPO).3 Unless the patient suffers complications of BPH such as renal failure, bladder stones or diverticula, recurrent urinary tract infection, and acute or chronic retention and surgery is performed on the enlarged prostate gland, treatment is targeted at reducing lower urinary tract symptoms (LUTS) that can be associated with but are not uniquely due to BPH. This is the reason why, in the lack of a univocal definition of BPE/BPH/BPO, most epidemiological work on BPH is based upon the incidence and prevalence of LUTS with the risk of including patients whose symptoms depend on causes other than BPH. Analysis of the General Practice Research database from the UK suggests that both incidence and prevalence of LUTS increase with age. Incidence values of 5 and 50 per 1,000 person-years were observed in men aged 45–49 and > 80 years, respectively. Prevalence increased from 3.5% in the fourth decade to 30% in men of 85 years or older.4 The increase of LUTS prevalence with age has been confirmed in several studies performed in different countries/populations although slight differences in the absolute age-specific prevalence value were observed.
Although BPH is an androgen-dependent condition (it does not develop in castrated men and families with a 5-alpha reductase deficiency), there is little evidence of an effect of hormone levels on clinical manifestations of the
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disease in population studies. Some degree of |
MTOPS.9 Using a stricter parameter such as |
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association has been found between BPH and |
increase of prostate volume of 26% or higher, |
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growth factors such as Insulin Growth Factor-1 |
22.6% of men progressed over a 4.2-year period |
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and its binding globulin (IGFBP-3). LUTS have |
in the population-based Krimpen study.8 PSA |
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also been correlated with sexual dysfunction |
concentration is known to be related to age and |
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and the relation holds true in different studies |
prostate volume; in the Krimpen study, a 5% |
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also after data were adjusted for age although no |
increase of serum PSA per year was seen. A |
||||
clear explanation has been found. A weak asso- |
shorter PSA doubling time was observed in men |
||||
ciation between clinical manifestations of BPH |
with BPH compared to those without it. Asian |
||||
and cardiovascular disease has been described. |
populations were recently investigated to obtain |
||||
No relation between LUTS and lifestyle factors |
epidemiological data on LUTS/BPH. Prevalence |
||||
(namely diet and exercise) has been observed. |
of LUTS is comparable to that observed in |
||||
Since surgical treatment of BPH was devel- |
Europe and USA with an 8% increase per decade |
||||
oped, the condition is no longer life-threatening |
(from 41.7% in the fifth decade to 65.4% in men |
||||
but remains progressive. Studies on the natural |
of 70 years or older). Although mean prostate |
||||
history of the disease tell us that an increase of |
volume in Japan community-based studies is |
||||
about 0.2 points/year in the IPSS scale is |
lower than in Caucasian-American and Africa- |
||||
expected; 50–80% of men will remain stable |
American series, Japanese prostates are more |
||||
over a 1–5-year period with a 20–50% progres- |
glandular. In Malaysia no difference in Qmax and |
||||
sion rate also depending on the definition of |
prostate volume was found among Chinese, |
||||
progression and type of population. The risk of |
Malay, and Indian populations.10 |
||||
acute urinary retention (AUR) varies from 2 to |
|
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||
18 per 1,000 person-years with lower values |
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||
observed in community studies (2–6.8%) and |
Pathophysiology |
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|||
higher ones in the placebo arms of clinical trials. |
|
||||
Age, symptom severity, and maximum flow rate |
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|
||
(Qmax) were independent predictors of AUR. In |
The term “prostatism,” suggesting a cohort of |
||||
the Olmstead County study, an age-related dete- |
symptoms deriving from the enlarging prostate, |
||||
rioration of flow rate was observed with a 1.3% |
has been replaced by the term “Lower Urinary |
||||
decrease per year in men in the 40s and 6.5% |
Tract Symptoms.”11 LUTS terminology was rede- |
||||
decrease in men in their 70s.5 Longitudinal stud- |
fined 8 years later and now includes filling/ |
||||
ies of voiding dynamics are rare. Thomas et al. |
storage, |
emptying/voiding, |
and postvoiding |
||
reported no significant increase of bladder out- |
symptoms (Table 27.1).3 Voiding symptoms are |
||||
flow obstruction over a 13.9-year period |
known to be more prevalent than storage ones |
||||
although decrease of detrusor contractility was |
althoughthesearemorebothersome.12 Frequency |
||||
found.6 The prostate gland tends to grow over |
with reduced voided volume may be associated |
||||
time; population studies suggested a 1.6–2.0% |
with detrusor overactivity, significant post-void |
||||
increase of prostate volume per year.7,8 A 4.5% |
residual, bladder neoplasms, fear of urinary |
||||
increase was observed in the placebo arm of the |
retention, |
and psychogenic |
causes. A small |
||
Table 27.1. lUts |
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Filling/storage |
Emptying/voiding |
Postvoiding symptoms |
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Frequency |
Hesitancy |
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Post-micturition dribbling |
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Urgency |
straining to void |
Feeling of incomplete emptying |
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nocturia |
Poor stream |
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Urgency incontinence |
intermittency |
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stress incontinence |
dysuria |
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nocturnal incontinence |
terminal dribbling |
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Bladder/urethral pain |
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absent or impaired sensation |
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|
363
BEnign Prostatic HyPErPlasia (BPH)
bladder capacity may occur because of fibrosis, |
examination; urinalysis; biochemical testing; |
|
noninfectious inflammatory disorders, irradia- |
post-void residual urine measurement, imaging, |
|
tion, and previous bladder surgery. Frequency |
and endoscopy of lower urinary tract (LUT) |
|
with normal voided volume may depend upon |
(Table 27.2, Figs. 27.1 and 27.2).13 |
|
polydipsia, osmotic diuresis, or diabetes insipi- |
History and physical examination aims at |
|
dus. Urgency (the sudden compelling desire to |
diagnosing concomitant conditions of the blad- |
|
void, which is difficult to defer), urgency inconti- |
der, the central nervous system, or other organs |
|
nence, and overactive bladder indicate neuro- |
that may be responsible for LUTS beyond benign |
|
genic origin (reduced suprapontine inhibition, |
and malignant disorders of the prostate. |
|
damaged axonal paths in the spinal cord, |
Frequency–volume charts are instrumental to |
|
increased afferent input to the lower urinary |
analyze dayand night-time frequency, mean |
|
tract, loss of peripheral inhibition, enhancement |
voided volume, total urine output, nocturnal |
|
of excitatory neurotransmission, in the micturi- |
urine output, urgency and urgency incontinence |
|
tion reflex pathway), myogenic (due to the effect |
episodes. Threeto seven-day charts are used |
|
of BOO on smooth muscle fibers) and structural |
with voided volumes recorded at least for 1 day. |
|
causes. Nocturia, defined as the need to wake up |
The instrument is accurate and inexpensive and |
|
at night to void, is a troublesome symptom that |
its widespread use should be encouraged. |
|
should always be distinguished from nocturnal |
Symptom score have been developed to stan- |
|
polyuria. Prevalence of nocturia increases with |
dardize the assessment of symptom severity by |
|
age and is sometimes considered part of the nor- |
using questions that have been psychometrically |
|
mal aging process.Voiding symptoms include all |
validated although they can also be used to pre- |
|
symptoms experienced during voiding. There is |
dict the response to treatment and to assess |
|
no pathophysiological correlation between these |
treatment outcome. Different symptom scores |
|
symptoms and urodynamic parameters of outlet |
are available and have been validated in several |
|
obstruction and this is why the term“obstructive |
languages (IPSS, ICIQMLUTS, Dan PSS, OABq); |
|
symptoms” has been dropped. The relation |
they all contain one or more questions about |
|
between LUTS and BPH is complex particularly |
quality of life and symptom bother. Although |
|
when epidemiological data suggested a similar |
the IPSS is the most popular symptom score, it |
|
prevalence in women.12 |
does not address urinary incontinence and may |
|
|
therefore be suboptimal whenever continence is |
|
|
impaired. Urinalysis is a recommended test also |
|
Patient Assessment |
at the primary level because it allows to diag- |
|
nose concomitant conditions that may or may |
||
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||
|
not be associated with LUTS such as hematuria, |
|
Patient assessment aims at establishing the |
but it is also instrumental in suspecting urinary |
|
tract infection, a common cause of LUTS. |
||
pathophysiology of LUTS in the individual sub- |
Although there is no association between BPE, |
|
ject and include: history taking, frequency– |
BPH/BPO, and chronic kidney disease, some |
|
volume charts, and symptom scores; physical |
national guidelines still recommend to measure |
Table 27.2. diagnostic tests |
|
|
Basic evaluation |
Specialized management |
|
Recommended tests |
Recommended tests |
Optional tests |
History |
detailed quantification of symptoms |
transrectal ultrasonography |
|
by validated questionnaires |
of the prostate |
assessment of symptoms and bother |
Uroflowmetry |
Ultrasound imaging of the upper |
|
|
urinary tract or intravenous |
|
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urography |
Urinalysis |
Post-void residual urine |
Endoscopy of the lower urinary |
|
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tract |
serum prostate-specific antigen (when |
Pressure-flow studies |
|
indicated) |
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Frequency–volume chart (voiding diary) |
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364 |
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Practical Urology: EssEntial PrinciPlEs and PracticE |
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Basic management of LUTS in men |
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Recommended Tests: |
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Complicated |
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LUTS |
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- |
Relevant medical history |
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LUTS: |
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- Assessment of LUTS |
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cause little or |
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- Suspicious DRE |
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symptom severity and |
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no bother |
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bother |
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- Hematuria |
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- |
Physical examination |
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- Abnormal PSA |
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including DRE |
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- Pain |
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Reassurance |
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- |
Urinalysis |
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- Infection3 |
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- Serum PSA1 |
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- Palpable bladder |
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and follow-up |
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- |
Frequency - volume chart2 |
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- Neurological |
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Predominant |
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disease |
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significant nocturia |
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Bothersome LUTS |
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Frequency-volume chart |
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Polyuria |
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No Polyuria |
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1 |
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Polyuria |
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24-hour output ≥ 3 liters |
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Standard Treatment |
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Lifestyle and fluid intake |
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- Alter modifiable factors |
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is to be reduced4 |
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Drugs |
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Fluide and food intake |
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Nocturnal polyuria |
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2 |
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- Lifestyle advice |
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≥ 33% output at night |
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Fluid intake to be |
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- Bladder training |
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reduced Consider |
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Drug treatment5 |
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desmopressin |
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1When life expectancy is > 10 years and if the diagnosis of prostate
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cancer can modify the management. |
Failure |
Success in |
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2 |
When significant nocturia is a |
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relieving |
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bothersome |
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predominant symptom. |
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LUTS: |
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3 |
Assess and start treatment before |
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referral. |
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Continue |
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4 |
In practice, advise patients with |
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symptoms to aim for a urine output |
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treatment |
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of about 1 liter/24 hours |
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Specialized management |
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5 |
See pages 10-12. |
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Figure 27.1. algorithm for basic management of male patients with lUts (From Mcconnell et al.13 with permission).
serum creatinine. Prostate-specific antigen (PSA) is recommended by most guidelines in patients with a life expectancy of 10 years or greater; the test can be used as a screening tool for prostate cancer, is a proxy for prostate volume, and is a good prognostic parameter for BPH progression. Measurement of post-void residual has been recommended as part of the initial evaluation although there is a weak
evidence for it. The relation between elevated PVR and UTI is in fact evident in the pediatric and neurogenic populations but scanty in the BPH patient. PVR values below 50–100 mL are considered to be normal and value >300 mL is used to identify patients at risk of unfavorable outcome. Imaging of the LUT includes bladder and prostate. Bladder imaging is usually performed for evaluating PVR but also provides
365
BEnign Prostatic HyPErPlasia (BPH)
Specialized management for persistent bothersome LUTS after basic management
|
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Recommended tests: |
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OAB |
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- Validated questionnaires |
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(Storage symptoms) |
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- FVC (frequency-volume chart) |
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No evidence of BOO |
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- Flowrate recording |
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- Residual urine |
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- Lifestyle |
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Evidence of BOO |
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MIST |
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Discuss Rx options |
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intervention |
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or |
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- Behavioral |
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shared decision |
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Surgery option |
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therapy |
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- Antimuscarinics |
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Medical therapy |
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option |
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Mixed |
OAB |
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Failure |
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Predominant BOO |
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and |
BOO |
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Reassess and |
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Antimuscarinics |
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Small gland/ |
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Larger |
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gland |
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and/or low PSA1 |
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and/or higher PSA2 |
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consider invasive |
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and |
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therapy of OAB |
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α-blockers |
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α-blockers |
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α-blockers + |
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5α-reductase inhibitors |
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(botulinum toxin |
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and |
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neuromodulation) |
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Failure |
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OAB: Overactive Bladder
BOO: Bladder Outlet
Obstruction
MIST: Minimally Invasive
Surgical Treatment
1PSA < 1.5 ng
2PSA > 1.5 ng
Offer MIST or Surgery to patient
Evaluation clearly suggestive of |
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obstruction ? (Qmax < 10ml/s) |
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NO |
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Pressure-Flow Studies |
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NO |
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Obstruction ? |
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YES |
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Treat appropriately. If inter- |
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ventional therapy is pursued, |
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patients need to be informed |
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Proceed with |
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of possibly higher failure rates |
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selected technique |
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Figure 27.2. algorithm for specialized management of male patients with persistent lUts following basic management (From Mcconnell et al.13 with permission).
information regarding possible comorbidities (bladder stones, diverticula, neoplasms, etc.), intravesical prostate protrusion, prostate volume, and bladder wall thickness. Transrectal imaging of the prostate cannot be used to diagnose or rule out prostate cancer in patients with LUTS but allows accurate evaluation of prostate
volume and gland morphology. Endoscopy is an optional test in all guidelines, because it cannot diagnose BPO although it may rule out concomitant disorders of the urinary bladder and urethra that may be responsible for LUTS. Urodynamics include different tests although uroflowmetry and pressure-flow study are most