A clinical guide to managing prostate disease

9 min

Prostate disease includes benign prostatic hyperplasia (BPH) and prostatitis. 

GPs are typically the first point of contact for men with these conditions. This article provides information on managing BPH and prostatitis, including clinical assessment, treatment, referral and follow-up.

Benign prostatic hyperplasia 

BPH is the non-cancerous enlargement of the prostate gland1. While not normally life-threatening, BPH can have a considerable impact on quality of life2.

Diagnosing benign prostatic hyperplasia

To diagnose BPH, review medical history for lower urinary tract symptoms (LUTS) and conduct a physical examination. You may also need to undertake additional tests. 

Medical history

BPH has several urinary symptoms. However, some men with BPH may not present with many or any symptoms of the disease.

Urinary symptoms of BPH

It is recommended that GPs use the International Prostate Symptom Score (IPSS)3 questionnaire to evaluate symptoms. This will assist in treatment allocation and response monitoring.

  • Obstructive symptoms:

    Hesitancy

    Weak stream

    Post micturition dribble

    Sensation of incomplete bladder emptying

  • Overactive symptoms:

    Frequency

    Frequency

    Nocturia

  • Other symptoms:

    Nocturnal incontinence

    Urinary retention

Physical examination

Conduct a thorough assessment that includes:

  • Digital rectal examination to estimate prostate size and identify other prostate pathologies

  • Basic neurological examination

  • Perianal sensation and sphincter tone

  • Bladder palpation

  • Calibre of the urethral meatus

  • Phimosis

Investigations

Investigations Available

  • Urine analysis

    Order a urinalysis or midstream urine.

    If you suspect urinary retention or large post-void residual volume:

    Order an ultrasound of the kidneys and bladder

    Check creatinine levels to assess renal function

Prostate-specific antigen (PSA) levels

Conduct a PSA test: 

  • If prostate cancer is suspected e.g. following a prostate examination

  • As part of screening for prostate cancer, after discussing pros and cons with the patient

As part of screening for prostate cancer, after discussing pros and cons with the patient.

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

PSA levels for different age groups of Western men:4

  • 40-49 years: 0.7 ng/mL (serum PSA median); 2.5 ng/mL (serum PSA upper limit of normal)

  • 50-59 years: 1.0 ng/mL (median); 3.5 ng/mL (upper limit)

  • 60-69 years: 1.4 ng/mL (median); 4.5 ng/mL (upper limit)

  • 70-79 years: 2.0 ng/mL (median); 6.5 ng/mL (upper limit)

Other PSA tests

Other PSA tests include creatinine levels, post-void residual urine (ultrasound) and PSA velocity (or doubling time). 

Assessing PSA velocity:

  • If the PSA level doubles in 12 months, it may indicate prostate cancer or prostatitis

  • An elevated PSA and a stable velocity suggests BPH

  • A high free-to-total PSA ratio (greater than 25%) suggests BPH; a low ratio (less than 10%) suggests prostate cancer

The Prostate Health Index (PHI) is not covered by the MBS. PHI is thought to be more specific for diagnosing prostate cancer than PSA level alone. But quality evidence is lacking, and it’s not recommended in Australian prostate cancer testing guidelines.

Investigations by a urologist

This can include:

  • Tests outlined in the section on GP investigations above

  • Uroflowmetry and post-void residual assessment

  • Voiding diary

  • ystoscopy

  • Urodynamic assessment

Managing benign prostatic hyperplasia

Managing BPH depends on the type and severity of symptoms.

Observation and review

  • This course of action is appropriate for mild or low-impact symptoms. .Optimise through reassurance, education, periodic monitoring and lifestyle modifications Consider adjusting medication e.g. timing of diuretic.

Medical therapy

Once daily alpha-blockers are used to manage moderate to severe symptoms.

  • Tamsulosin, silodosin or alfuzosin are generally the first options to try.

  • Side-effect profiles may favour tamsulosin.

5α-reductase-inhibitors (5ARIs) 

These include dutasteride and finasteride. 5ARIs are rarely used as monotherapy.

Combination therapy

Combining dutasteride and tamsulosin is better for patients with large prostates (greater than 30 ml). However, 5ARI can affect sexual function so consider it carefully in sexually active men. 

5ARI may be associated with prostate cancer risk so PSA surveillance is recommended. If PSA increases while the patient is on 5ARI, refer them to a urologist to exclude prostate cancer.

Other drugs

Bladder-directed medications are most commonly used for overactive bladder symptoms. 
They include:

Medications

Mirabegron, a beta-3 adrenergic agonist, which requires blood pressure monitoring within the first week.

Anticholinergics like oxybutynin, solifenacin, and darifenacin

Urologist referral

Refer the patient to a urologist if there are any of the following indicators:

  • Urinary retention history

  • rinary tract infection

  • Haematuria

  • Failed medical therapy

  • Incontinence (of any type)

  • Post-void residual greater than 100 ml

  • Post-void residual greater than 100 ml

  • Severe symptoms (especially if poorly responsive to medications)

  • Renal impairment

  • Bladder stones

  • Suspected prostate or bladder cancer

  • An 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. Stopping medication therapy usually results in the recurrence of symptoms.

The gold standard operation is transurethral resection of the prostate (TURP). However, there are many operations available, each with its pros and cons.

  • These include:

    Transurethral Incision of the Prostate (TUIP)

    Green light laser resection of the prostate

    Minimally invasive insertion of small retractors into prostate

    Plasma Vaporisation

    Water vapour therapy

    Holmium Laser Enucleation of the Prostate (HoLEP)

  • When determining a suitable operation for the patient, consider the following factors:

    Prostate size and configuration

    Anti-coagulation status

    Side effects e.g. preference to preserve antegrade ejaculation

    Day stay versus overnight stay in hospital

    Catheter duration

    Co-morbidities 

    Durability of operation

Long-term catheterisation is a last resort for patients unfit or unwilling for surgery but with complications e.g. urinary retention. In these cases, a supra-pubic catheter is preferred to an indwelling urethral catheter. GPs should also consider intermittent self-catheterisation.

Follow-up

It is appropriate for a GP to monitor and follow up with a patient, regardless of their treatment modality. However, if the patient is not responding to medical treatment, refer them to a urologist.

  • Observation and review:

    Observation and review: follow up at six months and annually thereafter

  • 5α-reductase inhibitors: follow up at 12 weeks, 6 months and annually thereafter

  • α-blockers

    α-blockers: follow up at six weeks, six months and annually thereafter

  • Surgery or minimally invasive treatment

    Surgery or minimally invasive treatment: follow up at six weeks, 12 weeks, six months and annually thereafter.

  •  Men who have had TURP remain at risk for prostate cancer and still need routine prostate cancer checks.

Prostatitis

Prostatitis is an inflammation of the prostate gland from bacterial or non-bacterial infection. Acute bacterial prostatitis is the least common form but can be serious if the infection is left untreated. 

Like BPH, prostatitis is rarely life-threatening, but quality of life can be severely affected.

Diagnosing prostatitis

Medical history

Look for urinary symptoms and pain.

  • Symptoms of prostatitis:

    Dysuria (painful urination)

    Urgent need to urinate

    Frequent urination

    Painful ejaculation

    Lower back pain

    Perineal pain

    Chills and/or fever

    Muscular pain

    General lack of energy

Investigations

Different Type of Investigations available:

  • Digital rectal examination: 

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

    Some tenderness and swelling may accompany sub-acute prostatitis

  • PSA levels: 

    Dramatically high

    If the PSA level doubles in 12 months, it may indicate prostate cancer or prostatitis

  • Urine analysis:

    First pass urine: chlamydia urine PCR test

    Midstream urine: MC&S

    Urine PCR for STIs if chlamydia or another STI is a likely cause

Managing prostatitis

There are several therapeutic options for prostatitis. There is limited evidence for benefits of these treatments; however, they may be trialled with the patient.

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

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

Treatment options

The type of treatment a urologist will use varies according to the patient, their condition and their stage of treatment. Most patients will have antibiotic therapy at some stage.

Medication

  • α-blockers:

    These are suited to patients with moderate to severe LUTS

    They include tamsulosin, silodosin and alfuzosin

    Side-effect profiles may favour tamsulosin

  • Antibiotics:

    Not all antibiotics penetrate the prostate gland.

    Recommended antibiotics are norfloxacin, ciprofloxacin, trimethoprim, sulphamethoxazole/trimethoprim, erythromycin and gentamicin.

    Young men with confirmed chlamydia prostatitis should be given doxycycline

Other medication options are analgesics and non-steroidal anti-inflammatory drugs.

Surgery

Surgery has a very limited role and requires an additional, specific indication e.g. prostate 
obstruction, prostate calcification. 

A transurethral incision of the bladder neck or a transurethral resection of the prostate are the options for surgery.

Other options

  • There are also treatments outside of medication and surgery. These include:

    Prostate massage

    Heat therapy

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

    Lifestyle changes, for example, avoiding activities involving vibration or trauma to the perineum (bike riding, tractor driving, long-distance driving), cutting out caffeine, spicy foods and alcohol, and minimising constipation

    Treatment by a specialised pelvic floor physiotherapist, which may include pelvic floor relaxation techniques and trigger point massage

Referral

Indicators for referral to a urologist:

  • The GP is not confident managing prostatitis

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

  • The patient does not respond to first-line therapies such as antibiotics or α-blockers. More invasive investigations, such as cystoscopy and a transrectal prostate ultrasound scan, are commonly done for these patients

Follow-up

  • 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 managing a relapse

Free clinical resource

Download the clinical summary guide as a print-ready PDF:
 
Prostate Disease

Keywords

Health practitioners
Prostate cancer
Prostate health
Prostatitis

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