The following investigations are not routinely recommended for the specialist assessment of bothersome LUTS by NICE (CG97).
Answer E
The NICE LUTS guidance 2010 recommends that in the specialist assessment of a patient with LUTS, the clinician should offer: An assessment of general medical history to identify possible causes and co-morbidities, including a review of all current medication (including herbal and over-the-counter medication) that may be contributing to the problem A physical examination guided by symptoms and other medical conditions, an examination of the abdomen and external genitalia, and a DRE (Jones et al., 2010).
Further tests include a flow rate and post-void residual volume measurement as well as a urinary frequency volume chart. Men should be offered information, advice and time to decide if they wish to have PSA testing if; their LUTS are suggestive of benign prostatic enlargement or the prostate gland feels abnormal or they are concerned about prostate cancer.
The guidance only recommends a cystoscopy and/or imaging of the upper urinary tract when there is a history of recurrent infection, sterile pyuria, haematuria, pain or chronic retention.
With reference to the MTOPS trial, which of the following is TRUE?
This study was a long-term, multi-centre double-blind trial (mean follow-up, 4.5 years) involving 3047 men to compare the effects of placebo, doxazosin, finasteride and combination therapy on measures of the clinical progression of benign prostatic hyperplasia. The risk of overall clinical progression (primary end points) – defined as an increase above base line of at least four points in the American Urological Association symptom score, acute urinary retention, urinary incontinence, renal insufficiency or recurrent urinary tract infection – was significantly reduced by doxazosin (39% reduction and finasteride (34%), as compared with placebo. The reduction in risk associated with combination therapy (66% for the comparison with placebo) was significantly greater than that associated with doxazosin or finasteride therapy alone. The risks of acute urinary retention and the need for invasive therapy were significantly reduced by combination therapy and finasteride but not by doxazosin (McConnell et al., 2003).
With reference to the PLESS trial, which of the following is NOT TRUE?
Answer D
This was a double-blind, randomised, placebo-controlled trial, where 3040 men with moderateto-severe urinary symptoms and enlarged prostate glands were treated daily with 5 mg of finasteride or placebo for four years. They were assessed with symptom scores, urinary flow rates, and the occurrence of outcome events every four months. Prostate volume was measured in a subgroup of the men. During the four-year study period, 10% in the placebo group and 5% in the finasteride group underwent surgery for benign prostatic hyperplasia (reduction in risk with finasteride, 55%). Acute urinary retention developed in 7% in the placebo group and in 3% in the finasteride group (reduction in risk with finasteride, 57%). The mean decreases in the symptom score were 3.3 in the finasteride group and 1.3 in the placebo group. Treatment with finasteride also significantly improved urinary flow rates and reduced prostate volume (McConnell et al., 1998).
It was the Prostate Cancer Prevention Trial (PCPT) that reported that 7 years of administration of finasteride reduced the risk of prostate cancer by 25% but with an apparent increased risk of high disease (Thompson et al., 2003).
Which of the following are important predictors for clinical progression of BPH?
A number of risk factors have been identified which can help predict disease progression in individual patients. An increased chance of disease progression is associated with age >70, symptom severity (IPSS > 7), reduced urinary flow rate (Qmax <10 mL/sec) and prostate size (>30 cc). Data from placebo arms of large drug trials has shown that PSA is an independent marker of disease progression. A PSA level of 1.4 ng/dL or higher indicates an increased risk of disease progression (McConnell et al., 2003).
The Olmsted County study measured the prevalence of symptoms of BPH in men aged 40–80. An average AUA symptom score deterioration of 0.18/yr was observed across the study with the fastest rate of deterioration observed in the 60–69 age group. Age greater than 70 is associated with a significant increase in risk of progression (Jacobsen et al., 1997).
Inflammation also appears to be important in the pathogenesis and progression of BPH. The risk of urinary retention has been found to be significantly greater in men with acute and/or chronic intraprostatic inflammation (ACI) than in those without.
Anticholinergics are contraindicated in the following, EXCEPT:
Answer B
Anticholinergics, such as oxybutynin chloride, are contraindicated in patients with untreated angle closure glaucoma since anticholinergic drugs may aggravate this condition. It is also contraindicated in partial or complete obstruction of the gastrointestinal tract, hiatus hernia severe gastroesophageal reflux, paralytic ileus, toxic megacolon complicating ulcerative colitis, severe colitis and myasthenia gravis. It is also contraindicated in patients with obstructive uropathy and in patients with unstable cardiovascular status in acute haemorrhage.
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