Male LUTS and BPH - What Do Pts Want
The Golden Rule, which crosses cultures and religions, is: ‘Do not do unto others what you would not want done to you’.
Patients rarely seek help for benign prostatic obstruction (BPO) unless acute urinary retention occurs, but they are rather referred for bothersome lower urinary tract symptoms (LUTS) associated with benign prostatic enlargement. Most Urologists experience suggests that patients are not interested in the diagnosis of bladder outlet obstruction; they care about improving their symptoms and quality of life and preventing disease progression. Research has pointed out that urgency/urge incontinence is the most bothersome symptom. Recently much space has been allotted for detection of Underactive Bladder associated with BPE and detection of Underactive Bladder has become paramount in decision making for surgical options. Another aspect that is gaining prominence is associated alterations in Sexual function, though this has not gained importance in all countries.
Comparing patient preferences for watchful waiting, drugs, and surgery is of interest but the comparison may be misleading, as indications for these different approaches can differ, although some overlap is expected. Many of the Drug Therapies do indeed have effect on sexual function and these will have to be discussed with the patient prior to commencing such treatments.
The real question, for which there is no high-level evidence, is what are the preferences and the expectations of the individual patient with male LUTS and BPE.
Sachin Malde, Kari AO Tikkinen* et al report that patients worry about urgency, nocturia, and frequency, and care about the different adverse events of the proposed treatments, showing that they are sometimes more to the point than we are. A weak urinary stream and prostate enlargement should never be considered per se as an indication for surgery. (PDF Provided).
Regarding surgical treatment of BPO, a number of minimally invasive treatments have been developed over the years to reduce unexpected risks and anticipated side effects of surgery. The need to administer anaesthesia is perceived as a risk, while ejaculatory and erectile dysfunction and urinary incontinence remain major concerns for patients. Among these four issues, ejaculatory dysfunction is an unmet need in BPO surgery, with only transurethral microwave therapy, transurethral needle ablation, second-generation temporary nitinol implantable device (iTind), Aquablation, Urolift, and Rezum procedures not including ejaculatory dysfunction as a potential issue in their informed consent. Though many literatures are now available on these procedures, most of these techniques are still considered investigational because of uncertain long-term outcomes.
Managing BPE involves much more than performing transurethral resection of the prostate. Urologists have a quiver full of different arrows to be used wisely for the comprehensive management of patients from diagnosis to treatment and follow-up. Patients do not seek a consultation to know what needs to be done, but rather to be informed about what can be done.
In this connection, it is important for us to familiarize with the current ‘ICS Report on Terminology for Adult LUTS’. We all have been following the ‘standardisation of terminology of LUTS’ as provided to us by Paul Abrams et al in 2002. Recently Carlos D’Ancona*, Bernard Haylen* et al have reintroduced the Report on Terminology with many changes making it necessary for us to know, understand to implement them.
https://onlinelibrary.wiley.com/doi/epdf/10.1002/nau.23897 (PDF available)
This must be read in detail and understood by all of us. Considerable space has been devoted to Pelvic Floor dysfunction which includes rectal problems, which I am not sure how much is needed for our enhanced knowledge of Male LUTS. I leave it to the readers.
A question that arises is whether Urodynamics will have to be performed prior to advising surgery for LUTS/BPO. Though Abrams stable has written much in favour (he has expressed this view in recent lectures he made in India), many in India still debate on the necessity for Urodynamic study prior to advising surgical treatments.
With warm Regards,