Prostatic
symptomsInvestigations
- Urine Glucose and protein
- U&E
- PSA (age 55-75)
- Uroflowmetry
- Ultrasound residuals
- International prostate symptom score
Refer if
- Large residual
- Suspicious PR
- PSA raised
- Low flow rate
Normal prostate values:
| Age(years) | Concentration (ng/ml) |
| 40-49 | 0 to 2.5 |
| 50-59 | 0 to 3.5 |
| 60-69 | 0 to 4.5 |
| 70-79 | 0 to 6.5 |
Ref: High result in prostate specific antigen test
M Mokete, A R Palmer, and K J O'Flynn
BMJ 2003;327 379
http://bmj.com/cgi/content/full/327/7411/379?etoc
More on PSA testing
Management
Benign prostatic hyperplasia leads to progressive clinical disease in a proportion of patients.
- Watchful waiting
-
Lifestyle modification
Reduce fluid or diuretic intake and/or modify behaviours to reduce the severity of symptoms and reduce the bothersome nature of the symptoms: avoid excess or night-time fluid intake, caffeine, and alcohol; void the bladder before long trips, meetings, or bed time. -
Antagonists are the most effective drug for improving lower
urinary tract symptoms and short term quality of life, and alfuzosin and tamsulosin (as once daily preparations) are the
safest options. - 5
Reductase inhibitors reduce prostatic volume by 20-30% but take
up to six months to improve symptoms. Both dutasteride and
finasteride decrease serum concentrations of prostate specific
antigen by about a half, and reference values need to be adjusted
if a patient is suspected of having or is being followed up for
prostate cancer. 5
Reductase inhibitors are more effective in patients with larger
prostates who are at high risk of progression of disease
- Long term combination therapy (alpha antagonist plus 5 alpha reductase inhibitor) decreases progression of disease in patients at high risk (IPSS >7, prostate vol >30ml, PSA raised, peak urinary flow rate <12ml/s, residual urine >100ml)
- Antimuscarinics for storage problems
For some men, symptoms of storage problems—such as urinary urgency (with or without urge incontinence), frequency, small urine volumes, and nocturia—in the absence of serious obstructive symptoms are predominant. Recently this symptom complex has been categorised as overactive bladder syndrome. For these men options such as bladder training, biofeedback, and antimuscarinic drugs (oxybutynin, tolterodine, trospium, solifenacin, and darifenacin) may be useful either alone or in combination with treatment that is more specifically directed at benign prostatic enlargement. Antimuscarinics should be used with caution in men with severe obstructive or voiding symptoms as these patients may have high residual urine volumes (more than 150 ml) and antimuscarinics have a theoretical risk of precipitating a deterioration of voiding symptoms including urinary retention. The evidence for this risk, however, is weak. - Surgery
Transurethral resection of the prostate results in the greatest improvement in symptoms and flow rate, but adverse effects include the risk of surgery. Minimally invasive and tissue ablative surgical techniques are being developed - repeat treatment is often needed with these techniques.
Urine flow rate test
- Patient should complete frequency/volume chart for 4 days before attending flow rate test.
- Patient must attend with full bladder.
Results of Uroflowmetry
Fairly normal flow with lowish voided volume. Note sharp rise and fall.
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Moderately obstructed but small volume voided. Note slope of falling side.
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Severely obstructed. This man considered himself to have a normal urinary stream.
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NICE referral guidelines
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