Clinical summary guide

Prostate disease

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Benign Prostatic Hyperplasia

The GP’s role (BPH)

Benign Prostatic Enlargement (BPE), usually due to Benign Prostatic Hyperplasia (BPH).

  • GPs are typically the first point of contact for men with BPE

  • The GP’s role in the management of BPE includes clinical assessment, treatment, referral and follow-up

Overview (BPH)

  • BPE is the non-cancerous enlargement of the prostate gland

  • Whilst not normally life threatening, BPE can impact considerably on quality of life

  • BPH is the most common microscopic (histological) diagnosis

Diagnosis (BPH)

Medical history:

  • Lower urinary tract symptoms (LUTS)

Urinary symptoms of BPH

Obstructive symptoms:

  • Hesitancy +/- straining

  • Weak stream

  • Post micturition dribble

  • Sensation of incomplete bladder emptying

Overactive bladder symptoms:

  • Frequency

  • Urgency (if severe incontinence)

  • Nocturia

Other:

  • Nocturnal incontinence

  • Urinary retention

Some men with BPH may not present with many or any symptoms of the disease.

Symptom score:

  • Evaluation of symptoms contributes to treatment allocation and response monitoring

  • The International Prostate Symptom Score (IPSS) questionnaire is recommended

Physical examination:

  • Bladder palpation

  • Phimosis

  • Calibre of the urethral meatus

  • Basic neurological examination

  • Perianal sensation and sphincter tone

  • Digital rectal examination (DRE) can estimate prostate size and identify other prostate pathologies but is not routinely required

Investigations:

  • Urinalysis or midstream urine (to exclude UTI/bacteruria/haematuria)

  • If urinary retention/large post void residual volume is suspected:

    Imaging – Ultrasound (Kidneys and bladder)

    Blood tests – Renal function (Creatinine)

  • PSA blood test:

    If suspect prostate cancer (e.g. based on risk assessment, prostate examination)

    As part of testing for prostate cancer, after discussion of pros and cons

    Routine PSA testing is not necessary for patients with BPH. Patients with LUTS are not at increased risk of having prostate cancer. LUTS are rarely a symptom of prostate cancer

    Other PSA tests

  • Other PSA tests:

    PSA velocity or doubling time: if the PSA level doubles in 12-months it may indicate prostate cancer or prostatitis

    Free-to-total PSA ratio: low ratio (< 10%) is more likely that prostate cancer is present

  • Post-void residual urine (bladder scan / ultrasound)

Investigations by the urologist:

  • As per GP investigations as indicated +/-

  • Uroflowmetry and post void residual assessment

  • Voiding diary

  • MRI Prostate (as part of prostate cancer risk assessment)

  • Cystoscopy

  • Urodynamic assessment

Management (BPH)

Observation and review for mild or low impact symptoms:

  • Optimise through reassurance, education, periodic monitoring and behaviour modifications (e.g. reduce diuretics, bladder irritants, evening fluid intake, constipation; bladder training, pelvic floor exercises)

  • Physiotherapists with advanced training/qualifications in pelvic floor physiotherapy can be very helpful across the spectrum

  • Consider adjustment of medication (e.g. timing of diuretic)

Medical therapy for moderate to severe symptoms (Alpha blockers (once daily)):

  • These are generally 1st line

    Tamsulosin

    Silodosin

    Alfuzosin

  • Adverse effects include:

    Ejaculatory dysfunction

    Erectile dysfunction

    Nasal congestion

    Hypotension

    Dizziness

    Tachycardia

  • Onset of effect takes days-weeks

  • Alpha blockers (particularly Tamsulosin) may complicate cataract surgery, so (if relevant) notify ophthalmologist before prescribing

5α-reductase-inhibitors (5ARIs)

  • Dutasteride

  • Finasteride

  • Adverse effects include5:

    Erectile dysfunction

    Decreased libido

    Decreased ejaculate volume

    Decreased semen count

    Gynaecomastia

  • Very rarely used as monotherapy

  • Onset of effect takes months

  • 5ARIs decrease PSA levels

Combination therapy

  • Dutasteride and tamsulosin

  • Better for patients with larger prostates (> 30-40 ml)

  • 5ARIs can affect sexual function, generally not used in younger, sexually active men

  • Controversy regarding 5ARI association with prostate cancer risk so recommend PSA surveillance. Long term (15 year) follow-up has shown no worse cancer outcomes. If PSA increases whilst on 5ARI (after adjustment ie. Doubling), refer to urologist for prostate cancer risk assessment

Other drugs

Phosphodiesterase type 5 inhibitors (PDE5Is) use is best for men with LUTS and erectile dysfunction (low-dose PDE5Is cost the same as alpha blockers)

PDE5Is used in combination with an α-blocker may be more effective than α-blocker alone.

Bladder directed medications are most commonly used for storage (overactive) bladder symptoms.

  • Beta-3 adrenergic agonist – Mirabegron

  • Requires blood pressure monitoring within first week

  • Anticholinergics

    Oxybutynin

    Solifenacin

    Darifenacin

  • Side effects include dry mouth, dry eyes and/or constipation

  • Use with caution in patients with glaucoma or advanced age (especially with cognitive impairment; may accelerate dementia)

Urologist referral

Treatment:

  • Urinary retention history

  • Urinary tract infection

  • Haematuria

  • Failed medical therapy

  • Incontinence (of any type)

  • Post void residual of < 100 ml

  • Severe symptoms (especially if poorly responsive to medications)

  • Renal impairment

  • Bladder stones

  • Cancer suspected — prostate or bladder

  • Associated neurological condition (e.g. Parkinson’s disease, Multiple sclerosis)

Surgery

Indications for surgery are similar to the indications for referral to a urologist.  Surgery can be considered when medications are no longer suitable for whatever reason. Cessation of medication therapy usually results in recurrence of symptoms. 

There are multiple operations available. The gold standard operation is a transurethral resection of the prostate (TURP). There are however numerous operations that are available. Each have their pros and cons.

When considering the operation the patient is to undertake, there are different factors that are considered such as:

  • Prostate size/configuration

  • Anti-coagulation status

  • Side effects (e.g. preference to preserve antegrade ejaculation)

  • Day stay vs overnight stay

  • Catheter duration

  • Co-morbidities (long term SPC)

  • Durability of operation

The operations available include:

  • Transurethral Resection of the Prostate (TURP)

  • Transurethral Incision of the Prostate (TUIP)

  • Green light laser photoselective vapourisation of the prostate

  • Minimally invasive insertion of small retractors into prostate (prostatic urethral lift; PUL)

  • Plasma Vaporisation

  • Water Vapour/Steam therapy

  • Holmium Laser Enucleation of the Prostate (HoLEP)

  • Long term catherisation:

    Last resort for patients unfit/unwilling for surgery but with complications (e.g. urinary retention)

    Supra-pubic catheter is preferred to indwelling urethral catheter

    Intermittent Self catheterisation should also be considered in such patients

Follow-up (BPH)

  • It is appropriate for the GP to monitor and follow-up a patient with respect to all the treatment modalities. However, if the patient is not responding to medical treatment, refer to the urologist

  • Men who have had TURP remain at risk for prostate cancer and need routine prostate cancer checks, as per guidelines

Table: Recommended follow-up timeline after BPH treatment

Prostatitis

The GP’s role (Prostatitis)

  • GPs are typically the first point of contact for men with prostatitis

  • The GP’s role in the management of prostatitis includes clinical assessment, treatment, referral and follow-up

Overview (Prostatitis)

  • Prostatitis is inflammation of the prostate gland

  • It can be a result of bacterial or non-bacterial infection

  • Acute bacterial prostatitis, the least common form, can be serious if the infection is left untreated

  • Whilst not normally life threatening, prostatitis can impact considerably on a man’s quality of life

Diagnosis (Prostatitis)

Medical history

  • Urinary symptoms

  • Pain

Symptoms of prostatitis

  • Dysuria — painful urination

  • Urgent need to urinate

  • Frequent urination

  • Painful ejaculation

  • Haematuria

  • Lower back pain

  • Perineal pain/discomfort

  • Chills and/or fever

  • Muscular pain

  • General lack of energy

Examination

  • Abdominal examination

  • Genital examination

  • Digital rectal examination (DRE):

    Should not be performed if you suspect acute severe prostatitis because it can be very painful

    Tenderness of prostate on palpation is diagnostic of prostatitis

Investigations

  • Urine analysis:

    First pass urine: Chlamydia urine PCR test

    Midstream urine: MC&S

    Urine PCR for STIs should be done if Chlamydia or other STI a likely cause

  • Prostate specific antigen (PSA) levels – generally not required but commonly performed:

    Levels may be dramatically high

    PSA velocity: if the PSA level doubles in 12-months it may indicate prostate cancer or prostatitis

Management (Prostatitis)

Treatment

  • There are several therapeutic options available. Evidence for benefits of these treatment options is limited; however, they may be trialled with the patient

  • Urologists’ use of the following forms of treatment will vary according to the individual, their condition and the stage of their treatment

  • Most patients will have antibiotic therapy at some stage

Bacterial prostatitis (acute and chronic) can be treated using antibiotics. Once diagnosed, rapid treatment is essential to avoid further complications. 

Acute bacterial prostatitis often occurs with cystitis.

Chronic nonbacterial prostatitis (chronic prostate pain syndrome); treatment is difficult and cure is often not possible. Treatment focus is on symptom management, to improve quality of life. Non-medical therapy is recommended as the initial treatment. 

For chronic prostatitis/chronic pelvic pain syndrome, the UPOINT system can aid management.

Medication options

Medication options

  • α-blockers

    Suited to patients with moderate/severe LUTS

    Tamsulosin

    Silodosin

    Alfuzosin

    Side effect profiles may favour tamsulosin

  • Antibiotics (not all antibiotics penetrate the prostate gland)

    Recommend: Norfloxacin, Ciprofloxacin, Trimethoprim, Sulphamethoxazole/Trimethoprim, Erythromycin, Gentamicin

    Young men with confirmed Chlamydia prostatitis: Doxycycline

    Fluoroquinolones (ciprofloxacin, norfloxacin) are subject to a USANZ warning due to risk of severe complications such as tendinopathy and aortic aneurysm and dissection.

  • Analgesics

  • Non-steroidal anti-inflammatory drugs

Surgery (eg. TURP/TUIP) has a very limited role and requires an additional, specific indication (e.g. prostate obstruction, prostate calcification). 

Other options

  • Lifestyle changes: avoid activity that involves vibration or trauma to the perineum (e.g. bike riding, tractor driving, long-distance driving, cut out caffeine, spicy foods, alcohol, avoid constipation)

  • Some patients may benefit from treatment by a specialised pelvic floor physiotherapist, which may include pelvic floor relaxation techniques and trigger point massage

  • Supportive therapy: biofeedback, relaxation exercises, acupuncture, massage therapy, chiropractic therapy and meditation

  • Heat therapy

Referral (Prostatitis)

Indicators for referral to a urologist.

  • When the GP is not confident in managing the condition

  • If the GP is concerned there are other potential diagnoses, particularly prostate or bladder cancer

  • Those who do not respond to initial first-line therapy such as antibiotics and/or a-blockers. For these patients, more invasive investigations, such as cystoscopy and transrectal prostate ultrasound scan, are commonly done

Follow-up (Prostatitis)

  • The need for urologist follow-up depends on the patient’s progress

  • Most urologists will refer back to the GP to monitor the progress of the patient

  • The urologist will seek re-referral if the patient’s progress is not satisfactory

  • A GP can re-refer if they do not feel comfortable in managing a relapse

Clinical review

Dr Matthew Roberts, University of Queensland

Prostate disease

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