Can simple tests performed in the primary care setting provide accurate and efficient diagnosis of benign prostatic hyperplasia? Rationale and design of the Diagnosis Improvement in Primary Care Trial

Male Incontinence: The Etiology or Basis of Treatment

CONTEXT

Elderly men are an increasing proportion of the aging population in the 21st century. Urinary incontinence reduces the quality of life and increases the burden of care for the aging population.

OBJECTIVE

The primary objective of this review is to explore the etiopathology of common causes of incontinence in aging male patients. The focus is on the algorithm of the initial evaluation of these patients from both a primary care and a urologic standpoint.

EVIDENCE ACQUISITION

A nonsystematic review of the literature was performed in September 2017. The data and evidence of this paper have been obtained by a PubMed search, and through official statements and recommendations from the International Consultation on Incontinence. Our search incorporated terms such as elderly, urinary incontinence, male, urodynamics, bladder outlet obstruction, BPH, neurologic, urethral stricture, spinal shock, and urethral sphincter injury.

EVIDENCE SYNTHESIS

A total of 7204 papers were identified; 6838 were excluded for female populations and populations <65 yr. A broad differential diagnosis exists for urinary incontinence in aging male patients, and many patients will be found to have multifactorial incontinence, compounding the issue. Neurologic etiologies common in this population include cerebrovascular accidents, Parkinson's disease, and dementia. Spinal cord injuries and multiple sclerosis are less common. In this analysis, non-neurologic etiologies leading to incontinence are broadly grouped under bladder outlet obstruction, sphincter injury, overactive bladder, underactive bladder, polypharmacy, and urinary tract infections.

CONCLUSIONS

We provide a review of the differential diagnosis of incontinence in an elderly male patient. There is a need for understanding etiopathology and recognizing that many patients may have a combination of the above. The assessment algorithm, modified from the International Continence Society, provides a pathway for the provider in evaluating and treating elderly patients.

PATIENT SUMMARY

In this review, we have identified the sources of urinary incontinence in elderly male patients by neurologic and non-neurologic causes. We also discuss the basic evaluation and workup of an incontinent patient.

Pelvic ultrasound evaluation for benign prostatic hyperplasia: prediction of obstruction

Global improvements in water quality, management of infectious diseases, and other medical therapeutics have resulted in a growing population of healthy aging men. One obligate anatomic consequence of aging for these men is the development of benign prostatic hyperplasia (BPH) with secondary bladder outlet obstruction. Although the voiding symptoms associated with the change in bladder health over time predominantly impact the quality of a man's daily experience, there are also significant medical consequences of BPH that require intervention. It is a challenge to distinguish men who are at risk for these medical consequences from the much larger population of older men with voiding symptoms (lower urinary tract symptoms, LUTS). A variety of national guidelines have been developed to establish a diagnostic paradigm for meeting this challenge, but all suffer from inadequate sensitivity for the early identification of men at risk for permanent bladder injury. It is likely that the application of a thorough pelvic ultrasound designed to identify the pertinent anatomic aspects of both the bladder and prostate will improve the sensitivity of these diagnostic paradigms, with subsequent improvement in the outcomes for men with BPH/LUTS.

Diagnosis of BPH and treatment of LUTS among GPs: a European survey

AIMS OF THE STUDY

This survey was conducted in France, Germany, Italy, Spain and UK, with the aim to assess diagnosis and therapy of BPH patients in clinical practice.

METHODS USED TO CONDUCT THE STUDY

A selected cohort of 455 general practitioners (GPs) in Europe were asked to report information on BPH patients with lower urinary tract symptoms (LUTS), including patient characteristics, diagnostic procedures, severity of illness, symptoms duration and underlying conditions. The GPs provided data relating to 886 patients.

RESULTS OF THE STUDY

The diagnostic work-up included description of symptoms (74.9-85.1%), rectal examination (55.4-82.1%) and the determination of PSA (79.1-94.7%). Transrectal sonography was popular in Italy and France (51.1% and 55.9%, respectively), less so in Germany (15.3%) and Spain (13.1%) and not at all in the UK (2.3%). At diagnosis, the most common symptom was nocturia (71-88%), followed by frequency (15-79%), urgency (43-68%) and weak stream (47-64%). The most common combination was the triad nocturia-frequency-feeling of incomplete emptying (22-31%). The mean ± SD LUTS severity score was similar in all countries: The main aim of treatment was the resolution of nocturia, which had an average score that reflected an important need (> 3.5) closely followed by frequency (3.3-3.9).

CONCLUSIONS DRAWN FROM THE STUDY AND CLINICAL IMPLICATIONS

This survey has shown that the most common LUTS is nocturia. Analyses of the symptoms' pattern revealed that the most common combination appears to be the triad nocturia-frequency-feeling of incomplete emptying. An association between LUTS and heart disease, diabetes and hypertension suggests that the pharmacological treatment should be devoid of effects on the cardiovascular system. With alpha blockers as first line treatment of LUTS, respondents were more concerned with hypotensive episodes resulting in falls, rather than about other typical side effects (e.g. ejaculation disorders and lowered libido). The survey highlights educational needs in diagnostics.

Can benign prostatic hyperplasia be identified in the primary care setting using only simple tests? Results of the Diagnosis IMprovement in PrimAry Care Trial

AIMS

Diagnosis IMprovement in PrimAry Care Trial (D-IMPACT) was a prospective, multicentre epidemiological study in three European countries to identify the optimal subset of simple tests applied in primary care to diagnose benign prostatic hyperplasia (BPH) in men who spontaneously present with lower urinary tract symptoms (LUTS).

METHODS

Consecutive male patients aged ≥ 50 years who spontaneously attended their regular general practitioner (GP) office with LUTS were eligible for inclusion if they had not previously undergone BPH diagnostic tests or received treatment for BPH. Patients were assessed on three occasions, twice by their regular GP (visits 1 and 2) and once by a urologist (visit 3). The diagnostic accuracy of each variable was determined using the urologists' final BPH diagnosis (at visit 3) as gold-standard. Independent variables analysed were as follows: age; BPH diagnosis performed by GP in visit 1 (yes/no); probability of BPH diagnosis assessed by GP in visit 1; urinalysis (normal/abnormal); prostate-specific antigen (PSA); International Prostate Symptom Score (IPSS); diagnosis of BPH performed by GP in visit 2 (yes/no); and probability of BPH diagnosis assessed by GP in visit 2. Statistically significant variables (p < 0.1) were included in a logistic regression model to identify the best algorithm and describe each test contribution.

RESULTS

The most frequent spontaneously reported LUTS were nocturia and weak urinary stream. BPH study prevalence was 66.0% (95%CI: 62.3-69.5) and 32% of patients were at risk of BPH progression (PSA > 1.5 ng/ml and prostate volume ≥ 30 cm(3)). Among the independent variables analysed, only age, IPSS and PSA showed a statistically significant relationship with BPH diagnosis. In a logistic regression model including age, IPSS, PSA and probability of BPH (based on physical examination and symptoms), positive predictive value (PPV) was 77.1%. Exclusion of BPH probability resulted in a PPV of 75.7%.

CONCLUSIONS

A diagnostic algorithm including only objective variables (age, IPSS and PSA), easily implemented in any GP office, allows GPs to accurately diagnose BPH in approximately three-quarters of patients spontaneously reporting LUTS.

A widespread population study of actual medical management of lower urinary tract symptoms related to benign prostatic hyperplasia across Europe and beyond official clinical guidelines

BACKGROUND

The estimated prevalence of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH) in men >50 yr of age is around 30%, similar in all industrialized countries. alpha(1)-Blockers and 5 alpha-reductase inhibitors (5-ARIs) are the two classes of drugs recommended by the European Association of Urology guidelines for the medical management of LUTS/BPH.

OBJECTIVE

To compare actual clinical practice across Europe with guidelines, we assessed the use of all BPH-related drugs (alpha(1)-blockers, 5-ARIs, and plants) among European countries with a large-scale quantitative and descriptive study.

DESIGN, SETTING, AND PARTICIPANTS

The amounts of BPH-related drugs prescribed in 19 European countries were obtained from the IMS Health database retrospectively from 2004 to 2008. Data were adjusted for each country by the number of people >50 yr of age.

MEASUREMENTS

We determined the "prescription index" related to BPH, defined for each drug per country by days of treatment sold per year divided by the number of men at risk divided by 365 d.

RESULTS AND LIMITATIONS

From 2004 to 2008, the yearly number of prescriptions was 11.6 million for 74 million people at risk. The global prescription index increased in all countries and was three-fold more important in southern countries than in northern ones. alpha(1)-Blockers are the most widely prescribed drugs, but the share of 5-ARIs is increasing. Phytotherapy prescription is country specific, varying from 0% to 40% of prescriptions and is not recommended by the guidelines.

CONCLUSIONS

Major variations were seen among European countries concerning the prescriptions related to BPH, although the prevalence of the disease and the guidelines are similar. These results underline the importance of feedback from actual clinical practice. Analysis of actual prescription levels would complement evidence-based medicine as critical material for public health analysis, recommendations, and health insurance policies.

STEP: simplified treatment of the enlarged prostate

We propose a simple and practical approach to the identification, evaluation and treatment of lower urinary tract symptoms (LUTS) resulting from an enlarging and obstructive prostate. The proposed Simplified Treatment for Enlarged Prostate (STEP) plan is a logical guide to patient management by the primary care provider (PCP). Symptoms of enlarged prostate (EP) are common and may frequently progress into a condition with profound adverse effects on quality of life. Despite the high prevalence, EP is underdiagnosed and undertreated. This situation may result from patient- and provider-related issues. Assessment of symptoms of EP should be initiated with a discussion of LUTS. Evaluation includes a focused history, physical examination and selected laboratory tests. Certain factors put the symptomatic patient at risk for disease progression; however, not all factors can be readily evaluated in the PCP setting. The serum prostate-specific antigen (PSA) level acts both as an indicator of prostatic size and a screening tool for prostatic cancer, and thereby provides an important tool for PCPs. The STEP plan is a logical guide to patient management. Step 1, watchful waiting, is appropriate in patients with symptoms that are not bothersome. If symptoms cause bother, the initiation of an alpha-blocker (AB) in step 2, provides relatively rapid symptom improvement. Patients with bothersome symptoms and a PSA > or = 1.5 ng/ml are at risk for progression and consideration should be given to combination treatment with an AB and a 5alpha-reductase inhibitor (step 3). Patients with refractory symptoms should be referred to a urologist (step 4). Identification, evaluation and management of EP are within the domain of the primary care setting. The STEP approach provides a simple and practical framework for PCPs to manage most men with symptoms of EP.