Dr. Daniel Ngui (biography and disclosures)
What I did before
Every family physician faces the challenge of very limited clinical interview time with patients for a multitude of problems. Thus, we need to have an efficient framework to deal with patients with Benign Prostatic Hypertrophy (BPH), as well as a need to overcome the fear of missing prostate cancer. I wanted to hone my approach to clinically assessing prostate size in combination with using PSA measurements and to improve my knowledge of how medications affect serial PSA tests, symptoms and outcomes in the management of BPH.
What changed my practice
By co-facilitating a family physician presentation with an urologist, Dr. Alan So in November 2009 “The Update on the Management of Benign Prostatic Hypertrophy” I re-examined what I learned from medical school and residency about how to diagnose and manage patients with BPH.
What I do now:
1) Improved documentation of BPH symptoms using a validated patient questionnaire
I am screening my patients with a BPH questionnaire with the International Prostate Symptoms Score (IPSS)1 to assess symptoms and effect on quality of life. I have found this tool to speed up my assessments and it helps document baseline symptoms in monitoring response to therapy. I often send this documentation with my specialists’ referral letters.
2) Having a more systematic approach to documenting the clinical exam of the prostate
Although there is not a standardized inter-tester method of using a digital rectal exam (DRE) to determine prostate size, Roehrborn2 looked at the correlation between prostate size on DRE and prostatic ultrasound. The bottom line for family physicians is to try estimating the prostate size by determining the number of finger-breaths from the midline to the lateral edge of the prostate. I now include a diagram of the prostate exam, including size in terms of fingerbreadths, shape, consistency and presence of nodules in my chart notes and referral letters. Also, Roehrborn3 has a useful graph illustrating how both age and PSA levels can be helpful in determining prostate volume. Using this PSA table in conjunction with examination findings of a patients’ prostate’s lateral edge being more than one fingerbreadths on either side of the midline, would indicate an enlarged prostate or a prostate volume over 30mL which is a key decision point for medical therapy.
3) Having an approach to using a PSA result in estimating the size of the prostate as well as knowing the effects of medications on PSA levels
Given that 5 alpha reductase inhibitors can shrink the prostate, it is important to know that PSA levels are reduced within 6 months after initiation of therapy. Having a baseline recording and doing a serial measurement to look for a failure to drop 50%4 or subsequent increases in PSA may indicate noncompliance, prostate cancer, or other prostate-related conditions requiring referral.
To address the concerns of prostate cancer, a standardized clinical exam and documentation using PSA test to help my assessment have been essential.
According to De La Rosette5 alpha blockers may fail over time and they may not significantly reduce the risk of long term negative outcomes. Two new key studies, MTOPS6 and CombAT7 help to give us some information about the benefits of treating BPH with monotherapy versus combination therapy. Both studies showed that treatment with combination alpha blockers and 5ARI therapy was superior to monotherapy for select groups of patients in terms of symptoms and outcomes.
4) I now refer to and utilize the Canadian Urological Association Clinical Practice Guidelines for BPH8
The bottom line for me in reviewing the guidelines is that I should try to focus on determining the degree of symptom severity and effect on quality of life. By knowing the approximate size of the prostate in conjunction with symptom severity and effect on quality of life one can decide to use either or both an alpha blocker or 5 alpha reductase inhibitor for medical therapy. Finally, by reviewing these guidelines, I feel most comfortable knowing when I have to refer my patient for further urologic workup and care.
References: (Note: Article requests require a login ID with the BC College of Physicians website or UBC)
- International prostate symptom score IPSS http://www.cpcn.org/ipss.pdf
- Roehrborn et al in Urology 49(4) 1997 (View article with: CPSBC or UBC)
- Roehrborn, Int J Impot Res 2008, 20(suppl3): s11-s18 (View article 1 with: CPSBC or UBC) 2008; 20(suppl3): s19-26. (View article 2 with: CPSBC or UBC)
- Kaplan SA et al. Urology. 2002; 60:464–468. (View article with: CPSBC or UBC)
- De La Rosette in Journal of Urology 2002; 167: 1734-1739 (View Abstract) (View article with UBC)
- McConnell et al NEJM 2003: 349; 2387-2398 (View article with: CPSBC or UBC)
- Roehrborn et al. J Urol 2008 179:616-621 (View article with: CPSBC or UBC)
- Canadian Journal of Urology 2005 12(3); 2677-2683 (View Abstract)