these guidelines have been withdrawn

These guidelines have been withdrawn MOH clinical practice guidelines are considered withdrawn five years after publication unless otherwise specified in individual guidelines. Users should keep in mind that evidence-based guidelines are only as current as the evidence that supports them and new evidence can supersede recommendations made in the guidelines.

MOH Clinical Practice Guidelines 1/2005

Ministryof Health

The Singapore UrologicalAssociation

Jan 2005

Levels of evidence and grades of recommendation

A(evidence levels Ia, Ib)

B(evidence levels IIa,

IIb, III)

C(evidence level IV)

GPP(good practice

points)

Requires at least one randomised controlled trial, as partof the body of literature of overall good quality andconsistency, addressing the specific recommendation.

Requires availability of well conducted clinical studies,but no randomised clinical trials on the topic ofrecommendation.

Requires evidence obtained from expert committee reportsor opinions, and/or clinical experiences of respectedauthorities. Indicates absence of directly applicable clinicalstudies of good quality.

Recommended best practice based on the clinical experienceof the guideline development group.

Grades of recommendation

Grade Recommendation

Levels of evidence

Level Type of Evidence

Ia Evidence obtained from meta-analysis of randomised controlled trials.

Ib Evidence obtained from at least one randomised controlled trial.

IIa Evidence obtained from at least one well-designed controlled study withoutrandomisation.

IIb Evidence obtained from at least one other type of well-designedquasi-experimental study.

III Evidence obtained from well-designed non-experimental descriptivestudies, such as comparative studies, correlation studies and case studies.

IV Evidence obtained from expert committee reports or opinions and/orclinical experiences of respected authorities.

CLINICAL PRACTICE GUIDELINES

MOH Clinical Practice Guidelines 1/2005

Published by Ministry of Health, Singapore16 College Road,College of Medicine BuildingSingapore 169854

Printed by Golden City Colour Printing Co. (Pte.) Ltd.

Copyright © 2005 by Ministry of Health, Singapore

ISBN 981-05-2850-7

Available on the MOH website: http://www.moh.gov.sg/cpg

Statement of Intent

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 dataavailable for an individual case and are subject to change as scientificknowledge advances and patterns of care evolve.

The contents of this publication are guidelines to clinical practice, based onthe best available evidence at the time of development. Adherence to theseguidelines may not ensure a successful outcome in every case. These guidelinesshould neither be construed as including all proper methods of care, nor excludeother acceptable methods of care. Each physician is ultimately responsible forthe management of his/her unique patient, in the light of the clinical datapresented by the patient and the diagnostic and treatment options available.

Foreword

Contents

1

1 Guidelines for Family Physicians

GPP

GPP

C

2

GPP

B

C

B

A

A

A

3

A

C

4

2 Guidelines for Urologists

GPP

C

C

C

B

5

B

B

B

B

B

C

6

C

B

B

B

C

7

C

B

A

A

8

3 Introduction

9

10

4 Assessment

GPP

11

GPP

C

C

12

C

B

B

B

B

13

14

Notobstructed

Obstructed Total

Grade 1 34 (79%) 9 (21%) 43 (100%)

Grade 2 35 (63%) 21 (37%) 56 (100%)

Grade 3 6 (6%) 95 (94%) 101 (100%)

Total 75 125 200

15

16

Parameter No obstruction Obstruction

I-PSS > 21 43% 57%

QOL ≥ 3 41% 59%

Qmax < 10 ml/s 20% 74%

RU > 100 ml 7% 93%

Prostate vol ≥ 30 ml 26% 74%

Grade 3 protrusion 6% 94%

17

B

B

18

B

19

C

C

20

5 Treatment

Stage Symptoms Outflow obstruction/Complications

ProposedTreatment

I Not bothered(QOL <3)

Not significant(residual urine <100 ml)

Watch

II Bothered(QOL ≥3)

Not significant(residual urine <100 ml)

Pharmacotherapy

III Irrespective Significant(uroflow <10 ml/s andresidual urine >100 ml)

Surgical option

IV Irrespective Retention of urine,bladder calculi,recurrent urinary tractinfection or persistentmacroscopichaematuria

Surgery (TURP)

21

B

B

C

A

22

B

C

GPP

23

A

A

A

A

24

B

A

25

A

A

26

27

28

6 Conclusion

29

References

30

31

32

33

34

35

Annex 1 I-PSS & QOL (English version)

36

Annex 2 I-PSS & QOL (Chinese version)

37

Annex 3 I-PSS & QOL (Malay version)

38

Annex 4 Different Stages of BPH and theirManagement

Different stages of BPH and their management22

Stage Symptoms Outflow obstruction/Complications

ProposedTreatment

I Not bothered(QOL <3)

Not significant(residual urine <100 ml)

Watch

II Bothered(QOL ≥3)

Not significant(residual urine <100 ml)

Pharmacotherapy

III Irrespective Significant(uroflow <10 ml andresidual urine >100 ml)

Surgical option

IV Irrespective Retention of urine,bladder calculi,recurrent urinary tractinfection or persistentmacroscopichaematuria

Surgery (TURP)

39

Parameters for evaluation

40

Self-assessment (MCQs)

41

42

43

The members of the workgroup, who were appointed in their personalprofessional capacity, are:

Chairman Dr Foo Keong TattSenior ConsultantDept of UrologySingapore General Hospital

Members

Workgroup members

A/Prof Chia Sing JooHead & Senior ConsultantDept of General SurgeryTan Tock Seng Hospital

Dr Enoch GanConsultant UrologistRaffles Hospital

Dr Ng Foo CheongChief & Senior ConsultantDept of UrologyChangi General Hospital

Dr Damian PngConsultant UrologistMD Specialist Healthcare

Dr Michael WongSenior ConsultantDept of UrologySingapore General Hospital

Dr David ConsigliereChief, Dept of UrologyNational University Hospital

Dr Lim Kok BinAssociate consultantDept of UrologySingapore General Hospital

Dr Jonathan Pang Sze KangEverhealth Family Clinic &Surgery

Dr Tan Kok LeongDirectorSingHealth Polyclinic (Outram)

Executive summary of recommendations

Details of recommendations can be found in the main text at the pages indicated.

Guidelines for Family Physicians

Identification and Evaluation

GPP When a patient is above 50 years of age and presents withlower urinary tract symptoms, history-taking should include these threebasic 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(Please refer to page 10)

GPP Conduct a clinical examination including:

• Digital rectal examination to assess size and exclude cancerof the prostate (when the prostate is hard and/or irregular).

• Abdominal examination to exclude palpable bladder.GPP

(Please refer to page 11)

MOH CLINICAL PRACTICE GUIDELINES 1/2005

Lower Urinary Tract Symptoms Suggestive ofBenign Prostatic Hyperplasia

1

GPP

GPP

C Conduct a urine labstix test to detect haematuria, pyuria andglycosuria.

Grade C, Level IV(Please refer to page 11)

C Offer the option of serum prostate specific antigen (PSA) test.

Grade C, Level IV(Please refer to page 11)

B Ultrasound examination of the urinary system may be considered. Thepurposes are to estimate residual urine and to detect hydronephrosis of thekidneys.

Grade B, Level III(Please refer to page 12)

Management

B In a patient with BPH without significant obstruction and withoutbothersome symptoms (Stage I): watchful waiting is an acceptable option.

Grade B, Level III (Please refer to page 21)

GPP Family physicians who are confident of evaluation of lower urinarytract symptoms (LUTS)/BPH can initiate treatment with medical therapy ifthe patient is bothered by his symptoms, has no significant residual urineand cancer of the prostate has been excluded.

GPP(Please refer to page 22)

A α-adrenergic blockers are recommended as first-line medical therapyfor patients with bothersome symptoms. They have been shown to beeffective in improving symptoms.

Grade A, Level Ia

(Please refer to page 23)

A 5 α-reductase inhibitors can be considered an acceptable first-linetreatment for patients with large glands.

Grade A, Level Ia

(Please refer to page 23)

2

C

GPP

C

B

B

A

A

A 5α-reductase inhibitors should be taken for at least 3 to 6 months to beeffective.

Grade A, Level Ia(Please refer to page 23)

A In the event that PSA is more than 2.0 µg/L, a urological assessment isrecommended.

Grade A, Level Ib

Indications for referral to a urologist

C Consider referring the patient to a urologist when he presents with orhas:

• Retention of urine;• Palpable bladder and/or high residual urine;• Incontinence;• Haematuria;• Proven UTI.• Persistent bothersome symptoms;• Bladder stones;• Hard and/or irregular prostate;• PSA > 4 µg/L (> 2 µg/L if on 5α-reductase inhibitors).

Grade C, Level IV(Please refer to page 22)

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 (Please refer to page 11)

3

(Please refer to page 23)

A

A

C

GPP

Indications for referral to a urologist

Recommended evaluation

C Offer the option of serum PSA test.Grade C, Level IV

(Please refer to page 11)

C Consider a voiding diary (frequency-volume chart) when nocturia isthe dominant symptom.

Grade C, Level IV(Please refer to page 12)

B Detect possible hydronephrosis with ultrasound of kidneys. This ismore sensitive than measuring serum creatinine levels to detect backpressure effect of obstruction.

Grade B, Level III(Please refer to page 12)

B Ascertain the post-void residual urine with transabdominal ultrasoundexamination.

Grade B, Level III(Please refer to page 12)

B Assess the size and the degree of intravesical prostatic protrusion (IPP)with transabdominal ultrasound scan. This information helps to predict thenatural history of the disease.

Grade B, Level III(Please refer to page 12)

B Assess severity and degree of bother of the patient’s symptoms usingthe International Prostatic Symptom Score (I-PSS) and the Quality Of Life(QOL) index.

Grade B, Level III(Please refer to page 17)

B Use uroflowmetry to determine the degree of urine flow impairment.

Grade B, Level III(Please refer to page 17)

C Conduct a urine labstix test to detect haematuria, pyuria and glycosuria.

Grade C, Level IV(Please refer to page 11)

4

C

C

B

B

C

B

B

B

Optional EvaluationThese investigations may be indicated for selected patients.

B Transrectal Ultrasound (TRUS) with biopsy is recommended forpatients with:

• Suspicious digital rectal examination findings;• Elevated PSA.

Grade B, Level III(Please refer to page 18)

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(Please refer to page 19)

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);• Haematuria.

Grade C, Level IV (Please refer to page 19)

Management

B In a patient with BPH without significant obstruction and withoutbothersome symptoms (Stage I): watchful waiting is an acceptable option.

Grade B, Level III(Please refer to page 21)

B In a patient with BPH with significant obstruction with or withoutbothersome symptoms (Stage III): surgery can be considered, if the patientis fit.

Grade B, Level III(Please refer to page 21)

5

B

C

C

B

B

B In a patient with BPH without significant obstruction but who hasbothersome symptoms (Stage II), after discussing with the patient, medicaltreatment with α-adrenergic blockers may be used for symptomatic relief,and 5α-reductase inhibitors for a gland of more than 40 gm.

Grade B, Level III(Please refer to page 22)

C The following conditions indicate complicated BPH (Stage IV) and aredefinite indications for surgery:• Repeated acute retention of urine;• Chronic retention of urine;• Bladder stones;• Recurrent urinary infections;• Recurrent or persistent gross haematuria;

Grade C, Level IV(Please refer to page 21)

B Prostatic stenting is indicated in elderly and frail patients at high riskfor surgery.

Grade B, Level III(Please refer to page 24)

A Transurethral microwave thermotherapy (TUMT) is not routinelyrecommended as a less invasive treatment of BPH.

Grade A, Level Ib(Please refer to page 25)

A Interstitial laser coagulation is not routinely recommended fortreatment of BPH.

Grade A, Level Ib(Please refer to page 25)

6

B

C

B

A

A