Benign Prostatic Hyperplasia With Outflow Obstruction

Clinical Implications And Therapeutic Strategies

Following the EAU guidelines on non-neurogenic male LUTS, one of the main goals in men presenting with LUTS is to obtain a diagnosis that may help outline the multifactorial causes of LUTS. A male patient presenting in primary care with LUTS may undergo thorough urological history taking and additional transrectal, transabdominal ultrasound or uroflowmetry to unravel the specific role of BOO and BPO. Subsequently, low-cost and effective therapeutic strategies could start early, initiated in primary care. These could include watchful waiting, pelvic floor muscle training, support of self-management, lifestyle advice or pharmacological treatment, including α1 adrenoceptor antagonists and 5α-reductase inhibitors. These options may suffice for some men to address their level of bother and could prevent unwanted surgery or invasive and burdensome diagnostic procedures in specialised urology clinics.

How Is Prostatic Obstruction Diagnosed

The diagnosis of prostatic obstruction typically involves questions from the doctor about the severity and type of symptoms experienced. Examinations may also be performed in the form of urine flow study, blood test, cystoscopy, ultrasound, MRI or rectal exam. If cancer is suspected a biopsy test will often be performed, along other tests depending on the stage of the cancer.

Does Having Benign Prostatic Hyperplasia Increase The Risk Of Prostate Cancer

Based on research to date, having BPH does not seem to increase the risk of developing prostate cancer. However, BPH and prostate cancer have similar symptoms, and a man who has BPH may have undetected cancer at the same time.

To help detect prostate cancer in its early stages, the American Urological Association and the American Cancer Society recommend a prostate screening every year for men ages 55 to 69. They also recommend that men who are at high risk such as African-American men and men who have a family history of prostate cancer begin screening at age 40. Screening tests for prostate cancer include a blood test for a substance called prostate-specific antigen and the digital rectal exam .

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How Is Benign Prostatic Hyperplasia Diagnosed

Your healthcare provider will review your medical history, ask you questions and perform a physical examination. Part of the physical exam involves a digital rectal exam.

During a digital rectal exam, your healthcare provider will carefully insert their gloved digit into your rectum. Theyll feel the edges and surface of your prostate, estimate the size of your prostate and detect any hard areas that could be cancer.

Your healthcare provider may also order:

• A survey to evaluate the severity of your symptoms.
• A urine flow test to measure the speed of your pee stream.
• A study to detect how much pee remains in your bladder after youve finished peeing.
• A cystoscopy to look into your bladder.

Benign Prostatic Hyperplasia With Lower Urinary Tract Symptoms

20162017 Revised Code20182019202020212022Billable/Specific CodeAdult Dx Male Dx

• N40.1 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
• Short description: Benign prostatic hyperplasia with lower urinary tract symp
• The 2022 edition of ICD-10-CM N40.1 became effective on October 1, 2021.
• This is the American ICD-10-CM version of N40.1 other international versions of ICD-10 N40.1 may differ.

• N40.1 is applicable to adult patients aged 15 124 years inclusive.
• N40.1 is applicable to male patients.

use additional code

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Surgical Treatment Of Bph

Surgery is normally recommended for patients with complications from BPH, who do not respond to medical therapy or who choose to have surgery as part of a definitive treatment.

A number of new developments are being researched, but at the time of writing there are three main options:

• Transurethral resection of the prostate
• Requires general or epidural anaesthetic.
• Surgeons insert a resectoscope into the urethra to see the prostate.
• The prostate is scraped away using an electrified wire loop. Afterwards a catheter is inserted and is left in place for up to 48-hours.
• TURP reduces the symptoms of BPH in 70-90% of patients, and peak urine flow rates of 15-20ml/second can be achieved reliably.
• However, in many men the prostate grows back and may necessitate a further TURP to reduce symptoms.
• Men cannot have children after this procedure.

• Robotic Prostatectomy

Penile Cuff Uroflowmetry And Penile Compression Manoeuvre

The method of manual penile compression by the patient to interrupt the flow midstream was analysed by one study. This manoeuvre was performed while voiding in a uroflowmetry device. An index was created based on two points from the recorded flow. With a cut-off index value of 96.4%, BOO based on Schäferâs obstruction grade could be predicted with a moderate sensitivity of 74% and good specificity of 94%. The level of evidence was graded as moderate for the validity of using a penile compression manoeuvre to indicate BOO, based on a good COSMIN score for criterion validity from a single study with a sufficient sample size . No measures of reliability were reported for this method .

Uroflowmetry using an automated inflating penile cuff was analysed by three studies. One study evaluated a similar compression index as beforementioned and found a moderate sensitivity and good specificity at an index cut-off value of 160% to predict BOO. The sensitivity for the measured maximum urinary flow with the penile cuff to predict BOO was good with a fair to good specificity of .

Based on the fair or good COSMIN scores for criterion validity, inconsistency of findings, number of studies and total sample size the level of evidence was graded as low for the validity to indicate BOO using uroflowmetry with an automated inflating penile cuff . Measures of reliability were not reported .

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Guidelines For The Treatment Of Benign Prostatic Hyperplasia

Yunuo Wu, PharmDCreighton University School of Pharmacy and Health Professions

Michael H. Davidian, MD, MSAssociate Professor of MedicineCreighton University School of Medicine

Edward M. DeSimone II, RPh, PhD, FAPhAProfessor of Pharmacy SciencesCreighton University School of Pharmacy and Health ProfessionsOmaha, Nebraska

US Pharm. 2016 41:36-40.

ABSTRACT:Benign prostatic hyperplasia is a common disorder in men with an incidence that increases with age. BPH often requires therapy when patients begin to experience lower urinary tract symptoms that affect quality of life. Current management strategies involve lifestyle modifications, pharmacotherapy, phytotherapy, and surgical interventions as indicated. Pharmacists are in the unique position of being accessible sources of healthcare information for the BPH patient population. Understanding the symptoms of this disorder and therapy options will be beneficial for pharmacists who have increased chances to answer BPH-related questions from their patients.

Two Mechanisms: Static Dynamic

BPH is a histologic diagnosis of proliferation of smooth muscle, epithelium, and stromal cells within the transition zone of the prostate, which surrounds the proximal urethra.

Symptoms arise through two mechanisms: static, in which the hyperplastic prostatic tissue compresses the urethra and dynamic, with increased adrenergic nervous system and prostatic smooth muscle tone . Both mechanisms increase resistance to urinary flow at the level of the bladder outlet.

The static component of benign prostatic hyperplasia and lower urinary tract symptoms, with hyperplasia leading to urethral compression.

The dynamic component of benign prostatic hyperplasia. The bladder outlet and prostate are richly supplied with alpha-1 receptors , which increase smooth muscle tone, promoting obstruction to the flow of urine. Alpha-1 adrenergic blockers counteract this effect.

As an adaptive change to overcome outlet resistance and maintain urinary flow, the detrusor muscles undergo hypertrophy. However, over time the bladder may develop diminished compliance and increased detrusor activity, causing symptoms such as urinary frequency and urgency. Chronic bladder outlet obstruction can lead to bladder decompensation and detrusor underactivity, manifesting as incomplete emptying, urinary hesitancy, intermittency , a weakened urinary stream, and urinary retention.

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Benign Prostatic Hypertrophy With Outflow Obstruction

You always take care of your body, but after some age, body changes is a natural process, and we can not control it.

For men, one of those body changes is the prostate gland gets bigger.

This gland becomes large as it becomes difficult to urinate. This problem is usually found only after 60 years, i.e., in older men.

What Are The Most Recent Relevant Guidelines

The most recent evidence-based recommendations in this field are the 2012 Guidelines on the Management of Male LUTS, published by the European Association of Urology . The American Urological Association and the United Kingdoms National Institute for Health and Clinical Excellence published guidelines for BPH and male LUTS, respectively, in 2010., Finally, the recommendations of the International Scientific Committee on the Evaluation and Treatment of Lower Urinary Tract Symptoms in Older Men were published in 2009.

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Others Forms Of Diagnosis

If the IPSS diagnosis appears inconclusive or suggests a possible problem, your doctor may recommend one of several other diagnostic procedures, including:

• Digital rectal examination used to assess the size and shape of the prostate gland.
• An abdominal examination to check whether the bladder can be felt .
• Urine and blood tests checking for infection or unusual cells.
• A prostate-specific antigen test. Increased levels of PSA often suggests prostate damage. A high PSA can indicate the presence of prostate cancer or BPH.
• Urine flow tests . Several different tests designed to measure urine flow. Peak flow rate, for example, tests for a flow rate of less than 15 ml/second. This often suggests an obstruction. However, urine flow measurements may also be affected by the bladder being unable to contract or shrink properly.
• Post-voidal residual urine measurement. This involves using ultrasound equipment to check the volume of urine left in your bladder after you have urinated. In general, volumes of 200ml or more suggest a problem and may prompt doctors to consider less conservative therapies.
• Trans-rectal ultrasound. This allows an accurate measurement of the volume of the prostate and may guide the physician in choosing the correct therapy.

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Strengths And Weaknesses Of The Study

Thirty-seven of the 61 studies scored at least one COSMIN-box âfairâ, âgoodâ or âexcellentâ. Nonetheless, this systematic review was hindered by the lack of definitions of measured constructs, minimal to no description of patient characteristics or how the diagnosis of BOO, BPO or benign prostatic hyperplasia was established.

Thirty-three of the included studies evaluated the criterion validity of assessment methods. The COSMIN describes criterion validity as the degree to which the scores of an instrument are an adequate reflection of a âgold standardâ. In the evaluation of BOO, urodynamic studies were often used to calculate a BOO Index , Schäferâs obstruction grade or International Continence Society nomogram to define obstruction. However, an overestimation or underestimation of the diagnostic accuracy could be present. Men with a score of > 40 on the BOO Index are defined as obstructed and below 20 are non-obstructed. Men with scores in between are described as equivocal, which some studies excluded from analysis, while other studies included these men in the non-obstructed group.

Also, in the evaluation of BPO, transrectal ultrasound was frequently used as reference test to measure prostate size. This is questionable, as it shows moderate values for the inter-rater reliability for smaller prostate sizes . If a poor reference test is used, the index test may incorrectly classify results as false positives or false negatives.

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What Are The Warning Signs Of Benign Prostatic Hyperplasia

Your prostate surrounds your urethra. When BPH causes your prostate to grow, it can cause blockage in your urethra. As a result, early symptoms of BPH include:

• Slowness or dribbling when you pee.
• Difficulty starting to pee.

• Kidney damage due to pee backflow from your bladder up to your kidney. The pee backflow increases pressure on your kidney.

Strengths And Limitations Of This Study

• This review consists of a broad and systematic search for literature in PubMed, Ebsco/CINAHL and Embase databases for studies on the evaluation of bladder outlet obstruction and benign prostatic obstruction in men with lower urinary tract symptoms.

• The identified literature evaluates a variety of assessment methods, thoroughly evaluated with the COSMIN checklist on all aspects of reliability and validity.

• A level of evidence was estimated based on methodological quality of the studies and precision, direction and consistency of the results.

• Studies with poor COSMIN scores were excluded from the best evidence synthesis, to strengthen conclusions and recommendations.

• Due to low methodological quality of many studies and inconsistencies in findings regarding the diagnostic accuracy, only a best-evidence synthesis was possible.

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Benign Prostatic Hyperplasia Nursing Care Plans

Benign prostatic hyperplasia or benign prostatic hypertrophy is characterized by progressive enlargement of the prostate gland , causing varying degrees of urethral obstruction and restriction of urinary flow. Depending on the size of the enlarged prostate, age and health of the patient, and the extent of obstruction, BPH is treated symptomatically or surgically.

Benign Prostatic Hypertrophy Symptoms

Benign prostatic hypertrophy refers to benign adenoma-like hyperplasia of the prostate around the urethra, leading to varying degrees of bladder outflow tract obstruction. The main difficulty in determining the prevalence of benign prostatic hyperplasia is the lack of a common definition, according to autopsy, histologically diagnosed as benign prostatic hyperplasia prevalence in men aged 31 to 40 years 8%, 51 to 60 years old male To 40% to 50%, age> 80 years old male incidence rate of more than 80%. According to clinical criteria, that is, prostate volume> 30ml and the international prostate symptom score is high, 55 ~ 74 years old without prostate cancer in men benign prostatic hyperplasia prevalence rate of 19%, and if the prostate volume> 30ml, the highest score, the largest Urine flow rate of 50ml as a standard, the incidence rate of only 4%.

Benign prostatic hyperplasia does not smoke alcoholism: prostate hyperplasia, fear of alcohol stimulation, otherwise it is easy to lead to autonomic disorders, causing urinary retention, smoking more of the same. Do not eat irritating food: due to irritation, such as spicy food will stimulate the prostate swelling increased, leading to increased or increased prostate hyperplasia. To maintain a good attitude: because after the angry can occur in varying degrees of urination inconvenience. So benign prostatichyperplasia for the daily life must maintain a good attitude, do not angry.

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What Are The Treatment Options For Prostatic Obstruction

The selection of treatments of prostatic obstruction depend on whether it is caused by cancer or benign enlargement. Examples of prostate cancer treatment are radiation therapy, chemotherapy, surgery etc. Below follow examples of how benign prostatic enlargement can be treated including examples of their respective advantages and disadvantages.

How Is Bph Managed And Treated

Before a doctor decides on the best treatment for your situation, he or she will consider:

• What your symptoms are and how serious they are.
• How much the symptoms affect your quality of life.
• The extent of urine flow reduction and if there is any urine remaining in the bladder after you have been to the toilet.

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Benign Prostatic Hyperplasia / Prostate Enlargement

Benign prostatic hyperplasia is a benign condition where the prostate continuous to grow as men get older it is a natural part of the ageing process. The enlarging prostate may squeeze the water pipe and limit the flow of urine, resulting in bladder outflow obstruction and difficulty passing urine. If left untreated complications such as urinary retention , chronic kidney disease, urinary tract infections and bladder stones may develop. BPH is a common condition, estimated to affect 1 in 2 men over the age of 50 to some degree and almost all men over the age of 80.

A detailed history and careful examination along with urine flow tests, a post-void bladder scan and urine testing in clinic will usually help to diagnose BPH and rule out sinister causes such as prostate cancer. Sometimes additional tests such as PSA blood test, MRI scan of the prostate, ultrasound of your kidneys and bladder, flexible cystoscopy or urodynamic investigations may be required.

Treatment options for BPH range from lifestyle changes to medical therapies to surgical interventions, of which there are many options. A careful discussion at your consultation will help to ascertain which of these will work best for you.

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Assessment Methods For Bpo

Nineteen studies evaluated assessment methods related to prostate size or intravesical prostatic protrusion, peripheral zone volume and transitional zone volume or transitional zone index to evaluate BPO due to benign prostatic enlargement, unless specified otherwise. An overview of the COSMIN scores per study on BPO is provided in .

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