Benign prostatic hyperplasia / LUTS — structured viva

Structured oral on BPH/LUTS: pathophysiology and the DHT story, assessment discipline (IPSS limits, PSA indications), the medical ladder with MTOPS and CombAT numbers, tadalafil for the overlap patient, surgical trade-offs from TURP to the MISTs, and watchful waiting defended with trial data.

Prompt

The examiner opens: 'A 62-year-old man with urinary symptoms has read online that an enlarged prostate means cancer. Take me through how you assess and manage him.' The viva branches through assessment discipline, risk stratification, medical therapy sequencing with trial evidence, the sexual-function consultation, escalation to procedures, and watchful waiting.

Stem

You are the GP. The man in front of you is frightened that his urinary symptoms mean cancer; he also wants 'the strongest tablet' so this never becomes an operation. ^[24]

References26Show

[14]McConnell JD, Roehrborn CG, Bautista OM et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. The New England journal of medicine, 2003.PMID 14681504
[12]Bautista OM, Kusek JW, Nyberg LM et al. Study design of the Medical Therapy of Prostatic Symptoms (MTOPS) trial. Controlled clinical trials, 2003.PMID 12689743
[16]Roehrborn CG, Siami P, Barkin J et al. The effects of combination therapy with dutasteride and tamsulosin on clinical outcomes in men with symptomatic benign prostatic hyperplasia: 4-year results from the CombAT study. European urology, 2010.PMID 19825505
[19]Roehrborn CG, Barkin J, Siami P et al. Clinical outcomes after combined therapy with dutasteride plus tamsulosin or either monotherapy in men with benign prostatic hyperplasia (BPH) by baseline characteristics: 4-year results from the randomized, double-blind Combination of Avodart and Tamsulosin (CombAT) trial. BJU international, 2011.PMID 21332630
[8]McConnell JD, Bruskewitz R, Walsh P et al. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group. The New England journal of medicine, 1998.PMID 9475762
[2]Gormley GJ, Stoner E, Bruskewitz RC et al. The effect of finasteride in men with benign prostatic hyperplasia. The Finasteride Study Group. The New England journal of medicine, 1992.PMID 1383816
[28]Corona G, Tirabassi G, Santi D et al. Sexual dysfunction in subjects treated with inhibitors of 5alpha-reductase for benign prostatic hyperplasia: a comprehensive review and meta-analysis. Andrology, 2017.PMID 28453908
[17]Roehrborn CG Efficacy of alpha-Adrenergic Receptor Blockers in the Treatment of Male Lower Urinary Tract Symptoms. Reviews in urology, 2009.PMID 20126606
[20]Egerdie RB, Auerbach S, Roehrborn CG et al. Tadalafil 2.5 or 5 mg administered once daily for 12 weeks in men with both erectile dysfunction and signs and symptoms of benign prostatic hyperplasia: results of a randomized, placebo-controlled, double-blind study. The journal of sexual medicine, 2012.PMID 21981682
[21]Roehrborn CG, Gange SN, Shore ND et al. The prostatic urethral lift for the treatment of lower urinary tract symptoms associated with prostate enlargement due to benign prostatic hyperplasia: the L.I.F.T. Study. The Journal of urology, 2013.PMID 23764081
[22]McVary KT, Gange SN, Shore ND et al. Treatment of LUTS secondary to BPH while preserving sexual function: randomized controlled study of prostatic urethral lift. The journal of sexual medicine, 2014.PMID 24119101
[25]Sønksen J, Barber NJ, Speakman MJ et al. Prospective, randomized, multinational study of prostatic urethral lift versus transurethral resection of the prostate: 12-month results from the BPH6 study. European urology, 2015.PMID 25937539
[26]McVary KT, Gange SN, Gittelman MC et al. Minimally Invasive Prostate Convective Water Vapor Energy Ablation: A Multicenter, Randomized, Controlled Study for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. The Journal of urology, 2016.PMID 26614889
[32]McVary KT, Gittelman MC, Goldberg KA et al. Final 5-Year Outcomes of the Multicenter Randomized Sham-Controlled Trial of a Water Vapor Thermal Therapy for Treatment of Moderate to Severe Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. The Journal of urology, 2021.PMID 33872051
[29]McVary KT, Roehrborn CG Three-Year Outcomes of the Prospective, Randomized Controlled Rezūm System Study: Convective Radiofrequency Thermal Therapy for Treatment of Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia. Urology, 2018.PMID 29122620
[30]Kasivisvanathan V, Hussain M Aquablation versus transurethral resection of the prostate: 1 year United States - cohort outcomes. The Canadian journal of urology, 2018.PMID 29900819
[35]Habib E, Abdallah MF, ElSheemy MS et al. Holmium laser enucleation versus bipolar resection in the management of large-volume benign prostatic hyperplasia: A randomized controlled trial. International journal of urology : official journal of the Japanese Urological Association, 2022.PMID 34788900
[34]Lerner LB, McVary KT, Barry MJ et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART II-Surgical Evaluation and Treatment. The Journal of urology, 2021.PMID 34384236
[36]van Kollenburg RAA, van Riel LAMJG, de Bruin DM et al. Novel minimally invasive treatments for lower urinary tract symptoms: a systematic review and network meta-analysis. International braz j urol : official journal of the Brazilian Society of Urology, 2023.PMID 37267609
[4]Wasson JH, Reda DJ, Bruskewitz RC et al. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. The New England journal of medicine, 1995.PMID 7527493
[24]Gratzke C, Bachmann A, Descazeaud A et al. EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction. European urology, 2015.PMID 25613154
[1]Barry MJ, Fowler FJ Jr, O'Leary MP et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. The Journal of urology, 1992.PMID 1279218
[10]Barry MJ Evaluation of symptoms and quality of life in men with benign prostatic hyperplasia. Urology, 2001.PMID 11750246
[9]Marberger MJ, Andersen JT, Nickel JC et al. Prostate volume and serum prostate-specific antigen as predictors of acute urinary retention. Combined experience from three large multinational placebo-controlled trials. European urology, 2000.PMID 11096237
[33]Mari A, Antonelli A, Cindolo L et al. Alfuzosin for the medical treatment of benign prostatic hyperplasia and lower urinary tract symptoms: a systematic review of the literature and narrative synthesis. Therapeutic advances in urology, 2021.PMID 33912246
[3]Isaacs JT Importance of the natural history of benign prostatic hyperplasia in the evaluation of pharmacologic intervention. The Prostate. Supplement, 1990.PMID 1689166

Benign prostatic hyperplasia / LUTS — structured viva

Stem

You are the GP. The man in front of you is frightened that his urinary symptoms mean cancer; he also wants 'the strongest tablet' so this never becomes an operation. ^[24]

References26Show

[14]McConnell JD, Roehrborn CG, Bautista OM et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. The New England journal of medicine, 2003.PMID 14681504
[12]Bautista OM, Kusek JW, Nyberg LM et al. Study design of the Medical Therapy of Prostatic Symptoms (MTOPS) trial. Controlled clinical trials, 2003.PMID 12689743
[16]Roehrborn CG, Siami P, Barkin J et al. The effects of combination therapy with dutasteride and tamsulosin on clinical outcomes in men with symptomatic benign prostatic hyperplasia: 4-year results from the CombAT study. European urology, 2010.PMID 19825505
[19]Roehrborn CG, Barkin J, Siami P et al. Clinical outcomes after combined therapy with dutasteride plus tamsulosin or either monotherapy in men with benign prostatic hyperplasia (BPH) by baseline characteristics: 4-year results from the randomized, double-blind Combination of Avodart and Tamsulosin (CombAT) trial. BJU international, 2011.PMID 21332630
[8]McConnell JD, Bruskewitz R, Walsh P et al. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group. The New England journal of medicine, 1998.PMID 9475762
[2]Gormley GJ, Stoner E, Bruskewitz RC et al. The effect of finasteride in men with benign prostatic hyperplasia. The Finasteride Study Group. The New England journal of medicine, 1992.PMID 1383816
[28]Corona G, Tirabassi G, Santi D et al. Sexual dysfunction in subjects treated with inhibitors of 5alpha-reductase for benign prostatic hyperplasia: a comprehensive review and meta-analysis. Andrology, 2017.PMID 28453908
[17]Roehrborn CG Efficacy of alpha-Adrenergic Receptor Blockers in the Treatment of Male Lower Urinary Tract Symptoms. Reviews in urology, 2009.PMID 20126606
[20]Egerdie RB, Auerbach S, Roehrborn CG et al. Tadalafil 2.5 or 5 mg administered once daily for 12 weeks in men with both erectile dysfunction and signs and symptoms of benign prostatic hyperplasia: results of a randomized, placebo-controlled, double-blind study. The journal of sexual medicine, 2012.PMID 21981682
[21]Roehrborn CG, Gange SN, Shore ND et al. The prostatic urethral lift for the treatment of lower urinary tract symptoms associated with prostate enlargement due to benign prostatic hyperplasia: the L.I.F.T. Study. The Journal of urology, 2013.PMID 23764081
[22]McVary KT, Gange SN, Shore ND et al. Treatment of LUTS secondary to BPH while preserving sexual function: randomized controlled study of prostatic urethral lift. The journal of sexual medicine, 2014.PMID 24119101
[25]Sønksen J, Barber NJ, Speakman MJ et al. Prospective, randomized, multinational study of prostatic urethral lift versus transurethral resection of the prostate: 12-month results from the BPH6 study. European urology, 2015.PMID 25937539
[26]McVary KT, Gange SN, Gittelman MC et al. Minimally Invasive Prostate Convective Water Vapor Energy Ablation: A Multicenter, Randomized, Controlled Study for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. The Journal of urology, 2016.PMID 26614889
[32]McVary KT, Gittelman MC, Goldberg KA et al. Final 5-Year Outcomes of the Multicenter Randomized Sham-Controlled Trial of a Water Vapor Thermal Therapy for Treatment of Moderate to Severe Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. The Journal of urology, 2021.PMID 33872051
[29]McVary KT, Roehrborn CG Three-Year Outcomes of the Prospective, Randomized Controlled Rezūm System Study: Convective Radiofrequency Thermal Therapy for Treatment of Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia. Urology, 2018.PMID 29122620
[30]Kasivisvanathan V, Hussain M Aquablation versus transurethral resection of the prostate: 1 year United States - cohort outcomes. The Canadian journal of urology, 2018.PMID 29900819
[35]Habib E, Abdallah MF, ElSheemy MS et al. Holmium laser enucleation versus bipolar resection in the management of large-volume benign prostatic hyperplasia: A randomized controlled trial. International journal of urology : official journal of the Japanese Urological Association, 2022.PMID 34788900
[34]Lerner LB, McVary KT, Barry MJ et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART II-Surgical Evaluation and Treatment. The Journal of urology, 2021.PMID 34384236
[36]van Kollenburg RAA, van Riel LAMJG, de Bruin DM et al. Novel minimally invasive treatments for lower urinary tract symptoms: a systematic review and network meta-analysis. International braz j urol : official journal of the Brazilian Society of Urology, 2023.PMID 37267609
[4]Wasson JH, Reda DJ, Bruskewitz RC et al. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. The New England journal of medicine, 1995.PMID 7527493
[24]Gratzke C, Bachmann A, Descazeaud A et al. EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction. European urology, 2015.PMID 25613154
[1]Barry MJ, Fowler FJ Jr, O'Leary MP et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. The Journal of urology, 1992.PMID 1279218
[10]Barry MJ Evaluation of symptoms and quality of life in men with benign prostatic hyperplasia. Urology, 2001.PMID 11750246
[9]Marberger MJ, Andersen JT, Nickel JC et al. Prostate volume and serum prostate-specific antigen as predictors of acute urinary retention. Combined experience from three large multinational placebo-controlled trials. European urology, 2000.PMID 11096237
[33]Mari A, Antonelli A, Cindolo L et al. Alfuzosin for the medical treatment of benign prostatic hyperplasia and lower urinary tract symptoms: a systematic review of the literature and narrative synthesis. Therapeutic advances in urology, 2021.PMID 33912246
[3]Isaacs JT Importance of the natural history of benign prostatic hyperplasia in the evaluation of pharmacologic intervention. The Prostate. Supplement, 1990.PMID 1689166