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CLINICAL PRACTICE Q&A
A CME PROGRAM FOR MEN’S UROLOGICAL HEALTH
BENIGN PROSTATIC HYPERPLASIALOWER URINARY TRACT SYMPTOMS
BPH-LUTS HOME

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STEERING COMMITTEE
Ghalib Ahmed, MD, CCFP
General Family Practitioner,
Associate Clinical Professor,
Department of Family Practice,
University of Alberta
Gerald Brock, MD, FRCSC
Professor of Surgery,
Urology Program Director,
University of Western Ontario
Chair Office of Education,
Canadian Urology Association
Lydia Hatcher, MD, CCFP, FCFP
Clinical Associate,
Professor of Family Medicine,
Memorial University of
Newfoundland
Murray Awde, MD, CCFP, FCFP
Clinical Professor of Family Medicine,
University of Western Ontario
Serge Carrier, MD, FRCSC
Associate Professor,
Division of Urology,
Department of Surgery,
McGill University
Jay Lee, MD, FRCSC
Clinical Assistant Professor,
Division of Urology,
Department of Surgery,
University of Calgary
Anthony Bella, MD, FRCSC
Greta and John Hansen Chair in Men's
Health Research,
Assistant Professor of Urology,
Department of Surgery,
Associate Scientist, Neuroscience,
University of Ottawa
Stacy Elliott, MD
Director, BC Center for Sexual Medicine,
Sexual Medicine Consultant,
Men’s Health Initiative,
Vancouver Coastal Health
Clinical Professor, Departments of
Psychiatry and Urologic Sciences,
University of British Columbia
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STEERING COMMITTEE DISCLOSURES
Ghalib Ahmed, MD, CCFP
• Grants/Research Support: AstraZeneca, Bristol-Myers Squibb,
Pfizer, Servier, Sunovion
• Speaker’s Bureau/Honoraria: Abbott, AstraZeneca, Eli Lilly,
Lundbeck, Merck, Pfizer, Shire
• Consulting Fees: Abbott, AstraZeneca, Bayer, Boehringer
Ingelheim, Bristol-Myers Squibb, Eli Lilly, Lundbeck, Merck, Pfizer
Murray Awde, MD, CCFP, FCFP
• Grants/Research Support: Astellas, Bristol-Myers Squibb,
Boehringer Ingelheim, Merck, Novartis, Otsuka, Purdue
Pharmaceuticals
• Speaker’s Bureau/Honoraria: Abbott, AstraZeneca, Bayer, LEO,
Takeda, Nycomed
• Consulting Fees: Boehringer Ingelheim, Bristol-Myers Squibb,
Eli Lilly, Merck, Novartis, Novo Nordisk, Pfizer
Anthony Bella, MD, FRCSC
• Grants/Research Support: Acorda Therapeutics, Canadian
Foundation for Innovation, Canadian Male Sexual Health Council,
Northeastern Section American Urological Association
• Speaker’s Bureau/Honoraria: Abbott, American Medical Systems,
Bayer, Coloplast, Eli Lilly, Pfizer
Gerald Brock, MD, FRCSC
• Grants/Research Support: American Medical Systems, Eli Lilly,
GlaxoSmithKline, Pfizer
• Speaker’s Bureau/Honoraria: American Medical Systems, Bayer,
Coloplast, Eli Lilly, GlaxoSmithKline, Pfizer
• Consulting Fees: Bayer, Eli Lilly, GlaxoSmithKline, Pfizer
Serge Carrier, MD, FRCSC
• Grants/Research Support: Bayer, Eli Lilly, Pfizer
• Speaker’s Bureau/Honoraria: Abbott, Bayer, Eli Lilly, Pfizer
Stacy Elliott, MD
• Speaker’s Bureau/Honoraria: Abbott, Bayer, Eli Lilly, Pfizer
• Consulting Fees: Abbott, Bayer, Eli Lilly, Pfizer
Lydia Hatcher, MD, CCFP, FCFP
• Grants/Research Support: Servier
• Speaker’s Bureau/Honoraria: AstraZeneca, Boehringer Ingelheim,
Eli Lilly, Janssen-Ortho, Merck, Nycomed, Pfizer, Purdue
Pharmaceuticals, Takeda, Valeant
• Consulting Fees: AstraZeneca
Jay Lee MD, FRCSC
• Speaker’s Bureau/Honoraria: Abbott, Bayer, Eli Lilly,
GlaxoSmithKline, Pfizer
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4
SPEAKER DISCLOSURES
• Faculty: [Speaker’s name]
•
•
•
•
Grants/Research Support:
Speaker’s Bureau/Honoraria:
Consulting Fees:
Other:
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5
DISCLOSURE OF COMMERCIAL SUPPORT
• This program has received financial support from Eli Lilly Canada Inc
in the form of an educational grant
• This program has received in-kind support from Eli Lilly Canada Inc
in the form of logistical support.
• Potential for conflict(s) of interest:
• [Speaker/Faculty name] has received funding Eli Lilly Canada Inc.
• Eli Lilly markets tadalafil, a product that will be discussed in this program.
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MITIGATING POTENTIAL BIAS
• All content in this presentation has been developed, reviewed and
approved by the Steering Committee
• All the recommendations involving clinical medicine are based on
evidence from well-designed clinical trials published in peerreviewed journals
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7. 77
BPH-LUTS
• The goal of this module is to address common questions in the area
of BPH-LUTS
• Benign prostatic hyperplasia is the histological pattern of the prostate, characterized
by proliferation of smooth muscle and epithelial cells within the prostatic transition
zone. This may lead to prostatic enlargement.
• Lower urinary tract symptoms refer to storage and/or voiding disturbances.
• BPH-LUTS refers to bothersome lower urinary tract symptoms
linked to the prostate
BPH: benign prostatic hyperplasia; LUTS: lower urinary tract symptoms.
1. Oelke et al. 2011 European Urology Association. Treatment Guidelines for Non-neurogenic LUTS; 2. Abrams et al. J Urol. 2009; 181:1779-87.
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BENIGN PROSTATIC HYPERPLASIALOWER URINARY TRACT SYMPTOMS
1
How should I
evaluate a patient
with BPH-LUTS?
3
How do I decide which
agent to prescribe for
BPH-LUTS?
5
2
Is there evidence of a
relationship between
BPH-LUTS and ED?
4
When should I refer a
patient to a urologist?
How should I follow-up
with a BPH-LUTS patient?
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BENIGN PROSTATIC HYPERPLASIALOWER URINARY TRACT SYMPTOMS
1
How should I evaluate
a patient with BPH-LUTS?
BPH-LUTS HOME

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10
LEARNING OBJECTIVES
• After completing this question participants will be able to:
• Identify diagnostic assessments for BPH-LUTS and integrate these into clinical
practice
• Evaluate the utility of PSA testing and recognize the CUA’s position on testing
• Distinguish the signs and symptoms of OAB from BPH-LUTS
CUA: Canadian Urological Association; OAB: overactive bladder; PSA: prostate-specific antigen.
BPH-LUTS HOME

11. HOW SHOULD I EVALUATE A
PATIENT WITH BPH-LUTS?
•
•
•
•
•
11
11
Medical history
Directed physical exam
Urinalysis
PSA testing
Symptom assessment
PSA: prostate-specific antigen.
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MEDICAL HISTORY
• Medical history should assess:1,2
•
•
•
•
•
•
Nature and duration of symptoms
Fluid intake – amount and types of fluid
Comorbid conditions
Prior and current illness
Prior surgery and trauma
Current medications
Do you routinely ask about sexual
function when evaluating a
patient for LUTS?
1. Nickel et al. CUAJ. 2010;4:310-6; 2. Abrams et al. J Urol. 2009;181:1779-87.
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BPH-LUTS AND ED
• BPH-LUTS and ED are common comorbid conditions
100
% of Patients with
Erectile Problems
90
80
50-59 yrs (n=5,786)
60-69 yrs (n=4,191)
70-79 yrs (n=2,828)
70
60
50
40
30
20
10
0
No symptoms
Mild
Moderate
Severe
Severity of LUTS
1. Rosen et al. Eur Urol. 2003;44:637-49.
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DIRECTED PHYSICAL EXAM
• Physical examination for patients with BPH-LUTS:1,2
• MANDATORY EVALUATION – DIGITAL RECTAL EXAM
• Evaluate prostate for size, consistency, shape and abnormalities suggestive of
prostate cancer (such as nodules or asymmetry)
• Assess suprapubic area to rule out bladder distention
• Evaluate overall motor and sensory function of the perineum and lower limbs
especially with a history of stroke or neurologic disease
1. Nickel et al. CUAJ. 2010;4:310-6; 2. Abrams et al. J Urol. 2009;181:1779-87.
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URINALYSIS
• Dipstick urinalysis should be performed in all BPH-LUTS patients
to rule out other diagnoses that may cause LUTS:
Urinalysis Result
Possible Diagnosis
• Hematuria
• Kidney stones
• Bladder cancer
• Pyuria or
presence of nitrates
• UTI
• Urethral stricture
• Proteinuria
• Underlying renal disease
• Glucosuria
• Diabetes
Abnormal/borderline urinalysis results should be repeated and/or
followed with a urine culture1
UTI: urinary tract infection.
1. Abrams et al. J Urol. 2009;181:1779-87.
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PSA TESTING
Do you currently recommend
PSA testing for your patients
with BPH-LUTS?
PSA: prostate-specific antigen.
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WHY PSA TESTING?
PSA can Help Predict Prostate Size
75
Prostate Volume (ml)
60
70
65
60
50
55
50
40
30
1
2
3
4
Serum PSA
5
6
7
ng/mL-1
Adapted from Roehrborn et al. Urology. 1999;53:581-9.
DRE: digital rectal exam; PSA: prostate-specific antigen.
1. Roehrborn et al. Urology. 1999;53:581-9.
BPH-LUTS HOME

18. PSA CAN IDENTIFY PATIENTS WITH HIGHER RISK
OF RETENTION OR SURGICAL INTERVENTION
Four Year Incidence (%)
26
18
18
Need for BPH-related surgery
Acute urinary retention
24
20
18
14
10
6
2
>0
>1
>2
>3
>4
>5
Baseline PSA Thresholds
>6
>7
>8
PSA: prostate-specific antigen.
1. Roehrborn et al. Urology. 1999;53:473-80.
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CUA RECOMMENDATIONS
FOR PSA TESTING
• The CUA position on PSA as a screening test for prostate cancer
DIFFERS from the USPSTF1
• CUA recommends PSA testing be offered to all men ≥50 years of age with a life
expectancy of ≥10 years.
• Canadian guidelines for the management of BPH-LUTS suggest PSA
testing for:2
• Patients who have at least a 10 year life expectancy, and for whom the presence of
prostate cancer would change management
• Patients for whom PSA measurement may change the management of their voiding
symptoms (estimate for prostate volume)
CUA: Canadian Urological Association; PSA: prostate-specific antigen; USPSTF: United States Preventive Services Task Force.
1. CUA position statement on PSA testing. November 2011; 2. Nickel et al. CUAJ. 2010;4:310-6.
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SYMPTOM ASSESSMENT
• Assess the severity of symptoms and degree of bother1
• Evaluate response to treatment
• Validated symptom assessment tools are available:
• International Prostate Symptom Score (IPSS)
• American Urological Association (AUA) symptom