Table 1. The summary of the recommendations of the Korean clinical practice guideline on benign prostatic hyperplasia.
| Recommendation | Level of recommendation | Level of evidence |
|---|---|---|
| 1. Is the IPSS questionnaire more helpful than a simple medical history for diagnosis during initial assessment in BPH patients? | ||
| 1-1. The IPSS is recommended for an objective assessment of symptoms at initial contact, for follow-up of symptom evolution for those on watchful waiting, and for evaluation of response to treatment. | Strong | B |
| 2. Is a voiding diary more helpful than a simple medical history to diagnose BPH patients? | ||
| 2-1. A voiding diary is helpful for clarifying the information obtained from history taking and for accurate diagnosis. | Strong | B |
| 3. Do uroflowmetry and measurement of PVR volume have advantages in the establishment of treatment strategy in BPH patients? | ||
| 3-1. Uroflowmetry can be conducted selectively in patients with lower urinary tract symptoms. | Strong | C |
| 3-2. Measurement of PVR volume can be conducted selectively in patients with lower urinary tract symptoms. | Strong | C |
| 3-3. Uroflowmetry and measurement of PVR volume can be conducted in patients with lower urinary tract symptoms and in those who need the specific evaluation of urologists. | Strong | B |
| 4. Does TRUS have a better role than DRE for the measurement of prostatic anatomy in BPH patients? | ||
| 4-1. For precise evaluation of prostatic anatomy, besides DRE, TRUS is warranted. | Strong | B |
| 5. Should PSA be measured in BPH patients? | ||
| 5-1. PSA should be measured in patients aged 40 years or older with LUTS. | Strong | A |
| 6. Does lifestyle modification have an advantage to improve symptoms in BPH patients? | ||
| 6-1. Watchful waiting is preferred for men with mild LUTS symptoms. | Strong | B |
| 6-2. Men with LUTS should be advised about lifestyle modification before and during treatment. | Strong | B |
| 7. Should medical treatment be considered first as the primary treatment ahead of surgical treatment in BPH patients? | ||
| 7-1. Medication therapy is recommended as a primary treatment in patients with moderate or severe symptoms. But surgical intervention is an appropriate treatment as an alternative for patients with moderate to severe LUTS and for patients who develop AUR or other BPH-related complications (bladder stone, bladder diverticulum, renal failure, hematuria). | Strong | B |
| 7-2. 5-Alpha-reductase inhibitors should be offered to men with moderate to severe lower urinary tract symptoms and enlarged prostate volume by DRE/prostate ultrasound or elevated serum PSA as BPH progression. | Strong | A |
| 7-3. Cholinergic receptor antagonists might be considered in men with moderate to severe lower urinary tract symptoms with predominant storage symptoms. However, caution is warranted for their use in men with bladder outlet obstruction. | Strong | A |
| 7-4. Alpha 1-blockers should be offered to men with moderate to severe lower urinary tract symptoms. | Strong | A |
| 8. Can combination therapy increase the treatment effect of alpha-blocker monotherapy in BPH patients? | ||
| 8-1. The combination therapy of 5α-reductase inhibitor and alpha-blocker is more effective treatment for improving lower urinary tract symptoms than alpha-blocker monotherapy in BPH patients. | Strong | A |
| 8-2. The combination therapy of anticholinergics and alpha-blocker is performed when the effect of alpha-blocker monotherapy is insufficient in patients with moderate to severe lower urinary tract symptoms. | Strong | A |
| 8-3. The combination therapy of anticholinergics and alpha blocker is carefully performed for men suspected of having bladder outlet obstruction and large postvoid urine volume. | Strong | A |
| 8-4. The combination therapy of phosphodiesterase type 5 inhibitors and alpha-blocker is more effective than alpha-blocker monotherapy in reducing moderate to severe lower urinary tract symptoms. | Weak | A |
| 9. Should TWOC be considered first before surgical treatment in BPH patients with AUR? | ||
| 9-1. TWOC should be considered first before surgical treatment in BPH patients with AUR. | Strong | A |
| 9-2. Alpha-blockers are helpful for treatment of AUR before/after indwelling urethral catheter. | Strong | B |
| 9-3. The optimal duration of urethral catheter indwelling is between 2 and 7 days after AUR. | Strong | B |
| 10. Is TURP considered the primary surgical treatment option in BPH patients rather than open prostatectomy? | ||
| 10-1. TURP is considered the primary surgical treatment option in BPH patients. | Strong | C |
| 10-2. Not only open prostatectomy but also endoscopic surgery is considered the primary treatment option, especially for prostate volume of 70 g or higher. | Strong | A |
| 11. What kinds of treatment can we recommend in patients inappropriate for surgical treatments for various reasons such as high-risk comorbidities? | ||
| 11-1. We can recommend intermittent or indwelling catheterization for patients inappropriate for surgical treatments. | Strong | B |
| 11-2. We can recommend the transurethral microwave thermotherapy or transurethral needle ablation as minimally invasive surgical therapies for patients inappropriate for to surgical treatments. However, patients should be aware of significant retreatment rates and less improvement in symptoms and quality of life in the aspect of long-term effects compared with transurethral resection of prostate. | Strong | A |
| 11-3. In some patients inappropriate for surgical treatments, intraprostatic injection of botulinum toxin or emergent materials are being tried and positive results are being reported but should be performed only in clinical trials. | Strong | A |
| 12. What diagnostic tests are necessary for follow-up and how should we set the period of follow-up in BPH patients? | ||
| 12-1. Follow-up for watchful waiting, medical, or surgical treatment is based on physicians' empirical data or preference. | Strong | C |
| 12-2. IPSS, DRE, PSA, uroflowmetry, PVR volume, and TRUS are recommended at follow-up visits for monitoring of disease progression. | Strong | C |
| 13. When should you refer BPH patients to urologists? | ||
| 13-1. If patients with lower urinary tract symptoms do not improve with primary medication, the patients should be referred to a urologist. | Strong | B |
| 13-2. If patients with lower urinary tract symptoms worsen with objective findings such as urinary tract infection, hematuria, and repetitive urinary retention, the patients should be referred to a urologist. | Strong | A |
| 13-3. If patients with lower urinary tract symptoms have abnormal results on a serum PSA test or DRE, the patients should be referred to a urologist for differential diagnosis of prostate cancer. | Strong | A |
IPSS, International Prostate Symptom Score; BPH, benign prostatic hyperplasia; PSA, prostate-specific antigen; LUTS, lower urinary tract symptoms; AUR, acute urinary retention; TWOC, trial without catheter; TURP, transurethral resection of the prostate; DRE, digital rectal examination; PVR, postvoid residual; TRUS, transrectal ultrasonography.