The Canadian Urological Society has released their latest guidelines on Benign Prostate Hyperplasia.
Did you know? We maintain an updated list of Canadian Primary Care guidelines relevant for the exam at www.thereviewcourse.com/guidelines - completely FREE!
WHAT'S NEW IN THE PROSTATE?
Turns out, not much. But there are some new medications and medication classes that you definitely want to be aware of, plus an EXAM TIP below.
UNCHANGED: DIAGNOSTIC ALGORITHM
First of all – the DIAGNOSTIC ALGORITHM has not changed. Eight years after the last edition of their BPH guidelines, it’s still the exact same algorithm with history, physical (DRE), and urinalysis as the only mandatory items.
NEARLY UNCHANGED: LIFESTYLE MODIFICATIONS
When it comes to LIFESTYLE modifications – there is still no change EXCEPT for the addition of ALCOHOL. Everything else is the same:
avoidance of caffeinated beverages, spicy foods
avoidance/monitoring of some drugs (e.g., diuretics, decongestants, antihistamines, antidepressants)
timed or organized voiding (bladder retraining)
pelvic floor exercises
and avoidance or treatment of constipation
FINALLY, SOME MAJOR CHANGES: MEDICATIONS
Since the 2010 guidelines were released, new evidence has emerged that recommends a few new steps in management of BPH. (Is it a coincidence that the companies that fund these pills have also written cheques to the guideline authors?)
EXAM TIP: Be sure you know both CLASSES and MEDICATIONS for the exam! But... you can write either generic OR trade names, according to the CFPC’s Instructions to the Candidate.
Here are the recommended medications and classes.
1. Alpha blocker
"Excellent 1st line." Options include Alfuzosin, doxazosin, tamsulosin, terazosin, and silodosin.
2. 5 Alpha-reductase inhibitor
"Appropriate and effective." Options include dutasteride and finasteride
"Appropriate and effective if symptomatic & enlarged prostate." You can consider stopping the alpha blocker after 6 months.
4. Antimuscarinics (anticholinergics) & Beta-3-agonist (new)
Useful if storage lower-urinary tract symptoms – caution if significant bladder outlet obstruction & postvoid residual. The Beta-3 agonist is the only one named in the guideline: Mirabegron
5. 1 + 4
May be useful in some men (if #1 has failed)
6. Phosphodiesterase type 5 inhibitors (new)
Recommended (previously not recommended) if male lower urinary tract symptoms PLUS BPH, particularly if lower urinary tract symptoms PLUS erectile dysfunction. The only one named in the guideline: Tadalfil
This is an option if the patient has nocturia. Could you list a major side effect? Monitor sodium!
8. Phytotherapies - not recommended
If you can master the above, you ensure a steady and full stream of success for your BPH patients. And if you can master all of the 99 topics, you can ace the CCFP exam.
Dr. Dhillon and I would love to have you join us at The Review Course Toronto 2019 - our last course for 2019 with open seats. We got outstanding evaluations for our most recent course in Vancouver this last weekend - our course is now better than ever!
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Dr. Jemy Joseph, one of our outstanding faculty, teaching at The Review Course - Vancouver - 2019