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## Complete Summary

#### GUIDELINE TITLE

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia.

#### BIBLIOGRAPHIC SOURCE(S)

Singapore Ministry of Health. Lower urinary tract symptoms suggestive of
benign prostatic hyperplasia. Singapore: Singapore Ministry of Health;
2005 Jan. 49 p. \[56 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Benign prostatic hyperplasia (BPH)\
Lower urinary tract symptoms (LUTS)

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Urology

#### INTENDED USERS

Health Care Providers\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To define the most cost-effective evaluation and treatment of benign
    prostatic hyperplasia (BPH) based on current medical evidence

-   To assist family physicians in the evaluation and treatment of BPH
    and to specify clinical situations when referral to an urologist is
    recommended.

#### TARGET POPULATION

Male patients in Singapore with lower urinary tract symptoms (LUTS)
suggestive of benign prostatic hyperplasia

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Evaluation**

1.  History of symptoms

2.  Digital rectal examination (DRE)

3.  Abdominal examination

4.  Urine labstix tests for haematuria, pyuria and glycosuria

5.  Serum prostate specific antigen (PSA) test

6.  Ultrasound of the kidneys, bladder and prostate

7.  Urogram (not recommended)

8.  Transabdominal ultrasound

9.  Voiding diary

10. Quantification of symptoms using the International Prostatic Symptom
    Score (I-PSS)

11. Quantification of symptoms using the Quality Of Life (QOL) index

12. Uroflowmetry

13. Transrectal Ultrasound (TRUS) with biopsy

14. Urodynamic Studies (UDS)

15. Flexible cystoscopy

**Treatment/Management**

1.  Watchful waiting

2.  Pharmacotherapy

    -   Alpha-adrenergic blockers (prazosin, terazosin, alfuzosin)

    -   5alpha-reductase inhibitors (finasteride, dutasteride)

3.  Transurethral resection of the prostate (TURP)

4.  Referral to a urologist

5.  Prostatic stenting

6.  Transurethral needle ablation (TUNA)

7.  Transurethral microwave thermotherapy (TUMT) (not routinely
    recommended)

8.  Laser prostatectomy

    -   Interstitial laser coagulation (not routinely recommended)

    -   Holmium laser resection (not recommended)

9.  Plasma-kinetic vaporization

#### MAJOR OUTCOMES CONSIDERED

-   Peak urinary flow rate

-   Obstruction rates for both kidneys and bladder

-   Rates of acute and chronic retention of urine

-   Incontinence rates

-   Retrograde ejaculation rates

-   Effectiveness, safety and adverse effects of interventions

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Level Ia**: Evidence obtained from meta-analysis of randomised
controlled trials

**Level Ib**: Evidence obtained from at least one randomised controlled
trial

**Level IIa**: Evidence obtained from at least one well-designed
controlled study without randomisation

**Level IIb**: Evidence obtained from at least one other type of
well-designed quasi-experimental study

**Level III**: Evidence obtained from well-designed non-experimental
descriptive studies, such as comparative studies, correlation studies,
and case studies

**Level IV**: Evidence obtained from expert committee reports or
opinions and/or clinical experiences of respected authorities

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

These guidelines were developed by a workgroup of urologists and general
practitioners from both public and private hospitals, Singapore Ministry
of Health, the College of Family Physicians, and the Singapore
Urological Association.

These guidelines provide recommendations that were adapted from the
recommendations of the International Consultations on Urological
Diseases. They were modified for local needs based on local clinical
research, availability of resources in Singapore and expert judgment.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendations**

**Grade A** (evidence levels Ia, Ib): Requires at least one randomised
controlled trial as part of the body of literature of overall good
quality and consistency addressing the specific recommendation

**Grade B** (evidence levels IIa, IIb, III): Requires availability of
well conducted clinical studies but no randomised clinical trials on the
topic of recommendation

**Grade C** (evidence level IV): Requires evidence obtained from expert
committee reports or opinions and/or clinical experiences of respected
authorities. Indicates absence of directly applicable clinical studies
of good quality.

**GPP** (good practice points): Recommended best practice based on the
clinical experience of the guideline development group

#### COST ANALYSIS

Published cost analyses were reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The recommendations that follow summarize the content of the guideline.
Please refer to the original guideline document for more detailed
recommendations. Each recommendation is rated based on the level of the
evidence and the grades of recommendation. Definitions of the grades of
the recommendations (A, B, C, Good Practice Points \[GPP\]) and level of
the evidence (Level I-Level IV) are presented at the end of the \"Major
Recommendations\" field.

**Guidelines for Family Physicians**

**Identification and Evaluation**

**GPP** - When a patient is above 50 years of age and presents with
lower urinary tract symptoms, history-taking should include these three
basic questions:

-   Do you get up more than once at night to pass urine?

-   Do you have to wait a long time to initiate urination and do you
    have a weak stream?

-   Are you bothered by your urination pattern?

Other important signs and symptoms include:

-   Blood in the urine (haematuria)

-   Uncontrolled leakage of urine (incontinence). **(GPP)**

**GPP** - Conduct a clinical examination including:

-   Digital rectal examination (DRE) to assess size and exclude cancer
    of the prostate (when the prostate is hard and/or irregular).

-   Abdominal examination to exclude palpable bladder. **(GPP)**

**C** - Conduct a urine labstix test to detect haematuria, pyuria, and
glycosuria. **(Grade C, Level IV)**

**C** - Offer the option of serum prostate specific antigen (PSA) test.
**(Grade C, Level IV)**

**B** - Ultrasound examination of the urinary system may be considered.
The purposes are to estimate residual urine and to detect hydronephrosis
of the kidneys. **(Grade B, Level III)**

**Management**

**B** - In a patient with benign prostatic hyperplasia (BPH) without
significant obstruction and without bothersome symptoms (Stage I):
watchful waiting is an acceptable option. **(Grade B, Level III)**

**GPP** - Family physicians who are confident of evaluation of lower
urinary tract symptoms (LUTS)/BPH can initiate treatment with medical
therapy if the patient is bothered by his symptoms, has no significant
residual urine, and cancer of the prostate has been excluded. **(GPP)**

**A** - Alpha-adrenergic blockers are recommended as first-line medical
therapy for patients with bothersome symptoms. They have been shown to
be effective in improving symptoms. **(Grade A, Level Ia)**

**A** - 5alpha-reductase inhibitors can be considered an acceptable
first-line treatment for patients with large glands. **(Grade A, Level
Ia)**

**A** - 5alpha-reductase inhibitors should be taken for at least 3 to 6
months to be effective. **(Grade A, Level Ia)**

**A** - In the event that PSA is more than 2.0 micrograms/L, a
urological assessment is recommended. **(Grade A, Level Ib)**

**Indications for Referral to a Urologist**

**C** - Consider referring the patient to a urologist when he presents
with or has:

-   Retention of urine

-   Palpable bladder and/or high residual urine

-   Incontinence

-   Haematuria

-   Proven urinary tract infection (UTI)

-   Persistent bothersome symptoms

-   Bladder stones

-   Hard and/or irregular prostate

-   PSA \> 4 micrograms/L (\> 2 micrograms/L if on 5alpha-reductase
    inhibitors) **(Grade C, Level IV)**

**Guidelines for Urologists**

**Recommended Evaluation**

**GPP** - Conduct a clinical examination including:

-   Digital rectal examination to assess size and exclude cancer of the
    prostate (when the prostate is hard and/or irregular)

-   Abdominal examination to exclude palpable bladder **(GPP)**

**C** - Conduct a urine labstix test to detect haematuria, pyuria, and
glycosuria. **(Grade C, Level IV)**

**C** - Offer the option of serum PSA test. **(Grade C, Level IV)**

**C** - Consider a voiding diary (frequency-volume chart) when nocturia
is the dominant symptom. **(Grade C, Level IV)**

**B** - Detect possible hydronephrosis with ultrasound of kidneys. This
is more sensitive than measuring serum creatinine levels to detect back
pressure effect of obstruction. **(Grade B, Level III)**

**B** - Ascertain the post-void residual urine with transabdominal
ultrasound examination. **(Grade B, Level III)**

**B** - Assess the size and the degree of intravesical prostatic
protrusion (IPP) with transabdominal ultrasound scan. This information
helps to predict the natural history of the disease. **(Grade B, Level
III)**

**B** - Assess severity and degree of bother of the patient\'s symptoms
using the International Prostatic Symptom Score (I-PSS) and the Quality
Of Life (QOL) index. **(Grade B, Level III)**

**B** - Use uroflowmetry to determine the degree of urine flow
impairment. **(Grade B, Level III)**

**Optional Evaluation**

These investigations may be indicated for selected patients.

**B** - Transrectal Ultrasound (TRUS) with biopsy is recommended for
patients with:

-   Suspicious digital rectal examination findings

-   Elevated PSA **(Grade B, Level III)**

**C** - Urodynamic Studies (UDS) are recommended:

-   When it is not certain whether outlet obstruction or neuropathic
    bladder is the cause of voiding dysfunction

-   For patients with bothersome symptoms but no clinical or ultrasound
    evidence of obstruction (no IPP)

-   For patients with previous surgery **(Grade C, Level IV)**

**C** - Flexible cystoscopy is recommended for patients with:

-   Previous lower urinary tract surgery

-   Obstruction suspected to be due to non-BPH causes (significant
    residual urine with small volume prostate and low IPP)

-   Hematuria **(Grade C, Level IV)**

**Management**

The guidelines recognize the different philosophies of treatment held by
practitioners. The following is a possible framework for selecting
treatment. Patient\'s age, general medical conditions, and preferences
should be taken into consideration.

Significant obstruction is defined by persistently high residual urine
(more than 100 mL) and low flow rate of less than 10 mL/s. This is
generally associated with prostate volume more than 40 gm and
significant IPP (more than 1 cm).

**B** - In a patient with BPH without significant obstruction and
without bothersome symptoms (Stage I), watchful waiting is an acceptable
option. **(Grade B, Level III)**

**B** - In a patient with BPH with significant obstruction with or
without bothersome symptoms (Stage III), surgery can be considered, if
the patient is fit. **(Grade B, Level III)**

**B** - In a patient with BPH without significant obstruction but who
has bothersome symptoms (Stage II), after discussing with the patient,
medical treatment with alpha-adrenergic blockers may be used for
symptomatic relief, and 5alpha-reductase inhibitors for a gland of more
than 40 gm. **(Grade B, Level III)**

**C** - The following conditions indicate complicated BPH (Stage IV) and
are definite indications for surgery:

-   Repeated acute retention of urine

-   Chronic retention of urine

-   Bladder stones

-   Recurrent urinary infections

-   Recurrent or persistent gross hematuria **(Grade C, Level IV)**

**B** - Prostatic stenting is indicated in elderly and frail patients at
high risk for surgery. **(Grade B, Level III)**

**A** - Transurethral microwave thermotherapy (TUMT) is not routinely
recommended as a less invasive treatment of BPH. **(Grade A, Level Ib)**

**A** - Interstitial laser coagulation is not routinely recommended for
treatment of BPH. **(Grade A, Level Ib)**

**Definitions**:

**Grades of Recommendations**

**Grade A** (evidence levels Ia, Ib): Requires at least one randomised
controlled trial as part of the body of literature of overall good
quality and consistency addressing the specific recommendation

**Grade B** (evidence levels IIa, IIb, III): Requires availability of
well conducted clinical studies but no randomised clinical trials on the
topic of recommendation

**Grade C** (evidence level IV): Requires evidence obtained from expert
committee reports or opinions and/or clinical experiences of respected
authorities. Indicates absence of directly applicable clinical studies
of good quality.

**GPP** (good practice points): Recommended best practice based on the
clinical experience of the guideline development group

**Levels of Evidence**

**Level Ia**: Evidence obtained from meta-analysis of randomised
controlled trials

**Level Ib**: Evidence obtained from at least one randomised controlled
trial

**Level IIa**: Evidence obtained from at least one well-designed
controlled study without randomisation

**Level IIb**: Evidence obtained from at least one other type of
well-designed quasi-experimental study

**Level III**: Evidence obtained from well-designed nonexperimental
descriptive studies, such as comparative studies, correlation studies,
and case studies

**Level IV**: Evidence obtained from expert committee reports or
opinions and/or clinical experiences of respected authorities

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate and cost-effective evaluation, management and treatment
    of patients with lower urinary tract symptoms and benign prostatic
    hyperplasia

-   Reduction in patient symptoms

#### POTENTIAL HARMS

-   *Transurethral resection of the prostate (TURP)*: Potential side
    effects include retrograde ejaculation, impotence, secondary
    hemorrhage, bladder neck stenosis, urethral strictures, recurrent
    adenoma.

-   *Alpha-adrenergic blockers (prazosin, terazosin, alfuzosin)*: Side
    effects include dizziness and orthostatic hypotension; use with
    caution in patients on antihypertensive medication and those with
    coronary artery disease or cerebrovascular accidents.

-   *5alpha-reductase inhibitors (finasteride, dutasteride)*: Side
    effects include diminished libido, reduced ejaculation, and
    impotence; may mask cancer development.

-   *Transurethral needle ablation (TUNA)*: Main side effects are
    retention of urine requiring catheterization for up to a month
    occasionally and urinary tract infection.

-   *Stents*: Problems of stent migration and possible stone formation
    in the long-term.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These guidelines are not intended to serve as a standard of medical
    care. Standards of medical care are determined on the basis of all
    clinical data available for an individual case and are subject to
    change as scientific knowledge advances and patterns of care evolve.

-   The contents of this publication are guidelines to clinical
    practice, based on the best available evidence at the time of
    development. Adherence to these guidelines may not ensure a
    successful outcome in every case. These guidelines should neither be
    construed as including all proper methods of care, nor exclude other
    acceptable methods of care. Each physician is ultimately responsible
    for the management of his/her unique patient, in the light of the
    clinical data presented by the patient and the diagnostic and
    treatment options available.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The following clinical audit parameters, based on the recommendations in
these guidelines, are proposed:

For family physicians: Percentages of family physicians who self-report
that they conduct the follow tests for all patients with lower urinary
tract symptoms (LUTS):

-   Digital rectal examination (DRE)

-   Abdominal examination

-   Urine labstix tests

[For urologists]{.underline}: Percentage of patients who have
complicated benign prostatic hyperplasia (BPH) with definite indications
for surgery\*:

-   Repeated acute retention of urine

-   Chronic retention of urine

-   Bladder stones

-   Recurrent urinary infection

-   Recurrent or persistent hematuria

-   Obstructive uropathy\
    who are offered surgery.

The initial audit would establish a baseline and subsequent audits would
allow a study of trends.

The audit would require case record reviews so only a sample of cases
may be audited.

\* one or more indications

#### IMPLEMENTATION TOOLS

Audit Criteria/Indicators\
Chart Documentation/Checklists/Forms\
Foreign Language Translations\
Patient Resources\
Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Singapore Ministry of Health. Lower urinary tract symptoms suggestive of
benign prostatic hyperplasia. Singapore: Singapore Ministry of Health;
2005 Jan. 49 p. \[56 references\]

#### ADAPTATION

These guidelines provide recommendations that were adapted from the
recommendations of the International Consultations on Urological
Diseases:

Chatelain CH, Denis L, Foo KT, et al.  5^th^ International consultation
on BPH \-- Recommendations of the International Scientific Committee:
Evaluation and treatment of lower urinary tract symptoms (LUTS) in older
men 2001.

#### DATE RELEASED

2005 Jan

#### GUIDELINE DEVELOPER(S)

Singapore Ministry of Health - National Government Agency \[Non-U.S.\]

#### SOURCE(S) OF FUNDING

Singapore Ministry of Health (MOH)

#### GUIDELINE COMMITTEE

Workgroup on Lower Urinary Tract

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Workgroup Members*: Dr Foo Keong Tatt (Chairman) Senior Consultant,
Dept of Urology, Singapore General Hospital; A/Prof Chia Sing Joo, Head
& Senior Consultant, Dept of General Surgery, Tan Tock Seng Hospital; Dr
Enoch Gan, Consultant Urologist, Raffles Hospital; Dr Ng Foo Cheong,
Chief & Senior Consultant, Dept of Urology, Changi General Hospital; Dr
Damian Png, Consultant Urologist, MD Specialist Healthcare; Dr Michael
Wong, Senior Consultant, Dept of Urology, Singapore General Hospital; Dr
David Consigliere, Chief, Dept of Urology, National University Hospital;
Dr Lim Kok Bin, Associate consultant, Dept of Urology, Singapore General
Hospital; Dr Jonathan Pang Sze Kang, Everhealth Family Clinic & Surgery;
Dr Tan Kok Leong, Director, SingHealth Polyclinic (Outram)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Singapore Ministry of Health Web
site](http://www.moh.gov.sg/mohcorp/publications.aspx?id=16360).

Print copies: Available from the Singapore Ministry of Health, College
of Medicine Building, Mezzanine Floor 16 College Rd, Singapore 169854.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Audit criteria, a continuing medical education (CME)
    self-assessment, and International Prostate Symptom Score (I-PSS)
    and Quality of Life Due to Urinary Symptoms (QOL) checklists (in
    English, Chinese, and Malay) are available in the [original
    guideline
    document](http://www.hpp.moh.gov.sg/HPP/1130910778681.html).

-   The full text guideline and summary card are available for PDA
    download in ISilo and MSReader formats from the [Singapore Ministry
    of Health Web
    site](http://www.moh.gov.sg/mohcorp/publications.aspx?id=16360).

#### PATIENT RESOURCES

The following is available:

-   Patient education brochure on Lower urinary tract symptoms
    suggestive of benign prostatic hyperplasia. Singapore: Singapore
    Ministry of Health; 2006 Feb. 5 p.

Electronic copies: Available in Portable Document Format (PDF) from the
[Singapore Ministry of Health Web
site](http://www.hpp.moh.gov.sg/HPP/MungoBlobs/1005/343/2005 Lower_Urinary_Tract_Symptoms.pdf).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on May 11, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Please contact the
Ministry of Health, Singapore by e-mail at <MOH_INFO@MOH.GOV.SG>.

### DISCLAIMER

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Date Modified: 11/3/2008