1. Benign Prostatic Hyperplasia Rajan Narula Senior Staff Specialist The Townsville Hospital

2. Assessment LUTS IPPS Voiding Diary DRE Urinalysis Serum creatinine PSA

3. Upper tract Imaging UTI/Urolithiasis/history of urosurgery/tumors/retention/hematuria USS generally adequate in uncomplicated LUTS CT and MRI no role in elderly uncomplicated LUTS

4. Assessment by Urologist Uroflowmetry Post void residuals (if not done earlier) Prostate size-TRUS or Suprapubic Ultrasound (if not done earlier)

5. Management options Expectant (Watchful waiting) Low IPPS, adequate flow, low PVR 85% stable at 1 year; 65% at 5 years EducationMay not progress ReassuranceCa Prostate MonitoringIPPS, PVR, Uroflowmetry Lifestyle adviceFluid intake, Constipation, Medications

6. Medical management 1 Medications Alpha Blockers Tamsulosin, Alfuzosin, Terazosin,Prazosin 20-50% reduction in IPSS 20-30% improvement in flow Ideally in patients with small prostates and no complicating factors,but can be used in larger Rapid action 24-48 hours Can be used for TOV after acute retention 4-8 week before ‘giving up’ Efficacy similar Side effects(10%) and price are decisive

7. Medical management 2 5 alpha reductase inhibitors Finasteride, Dutasteride Reduce size IPSS and Flow improvement Mean time for max. effect 6 months Prostate sizeshould be > 40 gm Costs++ PSAreal value is 2x of measured Side effects Minimal

8. Anticholinergic Antimuscaranic Selective M1-M3 receptor inhibitors Not essentially for BPH but when overactive bladder symptoms predominate Ditropan(Oxybutinin) Detrusitol(Tolterodine) Vesicare(Solifenacin) Enablex(Darifenacin ) Often required post TURP for shorter /longer periods.

9. Surgical management Failure of medical management Very high IPPS, poor flow, large PVR Complicating factors Bladder Stones Hematuria ARF Recurrent UTIs Retention/IDC OperationsTURP TUIP Millins HOLEP