Benign prostatic hypertrophy (BPH) causes lower urinary tract symptoms (LUTS) in almost half of men aged over 65.1 Of these, 51% report interference with at least one daily living activity.2
The UK has an estimated 2.5–3.4 million BPH sufferers. In 1991 about one in six people in the UK were aged over 65, and by 2021 this proportion is expected to be nearly one in five.3 This demographic shift, together with increased awareness of health issues among the general public and the development of new medical treatments for BPH, has led to more patients presenting with LUTS.
The cost of BPH (including NHS and indirect costs) was estimated at between £62 million and £91 million in 1990, the largest component being inpatient treatment.4
The diagnosis and management of prostatic disorders have traditionally been handled by urologists, but it is recognised that referral to hospital is not always appropriate.
The number of urologists in the UK is unlikely to keep pace with the incidence of BPH and related diseases and therefore the role of the secondary sector is very likely to change. Coping with the challenge will depend on hospitals and general practice shring the caseload effectively.
Highcliffe Medical Centre probably has the oldest practice population in the UK. With around 45% of patients aged over 65, and 2900 men aged over 50, it offers a crystal-ball view of the future of the NHS.
Initial work to develop a primary-care based, primary-care led urology service began in October 1993. The idea came about following a practice-based health needs assessment which showed that transurethral prostatectomy (TURP) was the most commonly performed non-diagnostic surgical procedure. More than 25% of procedures were undertaken for acute retention of urine. Further research revealed that prostate disease represented an unmet need, not only in our community, but also in the UK generally.
During the same year, the shared-care initiative was suggested by a UK working party, which incorporated comments and ideas from 2000 clinicians.5 This provided us with a starting point for discussion.
In February 1994 a case for the development of a community-based, shared-care urology service was put to the Dorset Health Authority. The following urology shared-care objectives were identified:
- Improve patient access to male urological assessment
- Reduce inappropriate referrals to outpatients
- Reduce unnecessary outpatient appointments before and after investigation for patients in need of referral
- Allow medical management of BPH where appropriate
- Allow audit and research
- Achieve cost-effective use of resources
- Achieve resource control linked to measured clinical need.
With the support of the Dorset Health Authority, and consultant urologists at Bournemouth and Southampton Trust Hospitals, the Highcliffe shared-care urology clinic began work in January 1995. It is currently funded through an extended primary care services budget, held at PCG level.
Clinic shared-care strategy
In 1989, Ter Hald defined BPH as a combination of three factors:6
- LUTS as evidenced by symptoms and bother
- Bladder outflow obstruction causing reduced urinary flow rate
- Benign prostatic enlargement on clinical examination.
A multifactorial approach to diagnosis is required. By performing investigations to assess the severity and complications of the condition, the Highcliffe service takes the first step in identifying which resources should be allocated to individual patients, including whether they require primary or secondary care.
Given the uncertainty about the natural history of BPH, we believe it essential that patients are allowed to play a large part in treatment choice within the current framework, which has evolved over the years according to the available evidence.
The initial clinic assessment fulfils all the obligatory criteria outlined in the 1997 Royal College of Surgeons and British Association of Urological Surgeons joint guidelines (see Table 1, Table 2, Figure 17,8 and Figure 2, below).
Note: Follow-up clinic post-micturition residual urine in milliltres – BARD diagnostic ultrasound bladder scan
|Figure 1: International prostate symptom score (IPSS) 7,8|
|Figure 2: Quality of life assessment index|
Patients with normal digital rectal examination (DRE), age-adjusted prostate-specific antigen (PSA) values, post-micturition residual volume (PMRV) and urinary flow rate, with no other unaccountable symptoms or signs, can be managed by the GP.
Red flag symptoms and signs
- These indicate the need for referral or discussion with secondary care:
- PMRV >200ml
- Severe obstructive picture: maximum flow rate <8ml/s
- Severe irritable symptoms – need to exclude bladder pathology
- Recurrent urinary tract infections
- Renal impairment – abnormal creatinine, upper urinary tract dilatation
- Suspicious DRE
- Elevated age-related PSA.
This can be considered for patients with:
- Moderate symptoms (IPSS score 8–19)
- Severe symptoms (IPSS score 20–35) and unfit for or awaiting surgery
- Significant bother factor as estimated by the quality of life assessment index
- Reduced maximum flow rate (<15ml/s).
We now have evidence that appropriate medical intervention can be used to achieve a complete management strategy.
Although the Veterans Affairs (VA) study9 had suggested that there was no difference between finasteride and placebo, a meta-analysis of six double-blind, placebo-controlled trials suggested that finasteride was the drug of choice if the prostate was >40cm3 in size. The VA study did highlight the efficacy of alpha-blockers, which work by relaxing smooth muscle tissue, in BPH patients.
It has been demonstrated that finasteride can prevent long-term complications of BPH, including acute retention of urine.10
The choice of therapy must therefore be guided by the estimated size of the prostate gland (on DRE and on transabdominal ultrasound), co-morbidity, existing medication and symptom severity.
A strategy of 'watchful waiting' can be adopted for patients who do not require or want any other form of management.
There is significant variability in the natural history of LUTS suggestive of benign prostatic obstruction, with 40–56% of men improving spontaneously.11–14
In men who are not too bothered by their symptoms, lifestyle modification and a period of observation and re-assurance may be all that is required.
Careful follow-up and easy access to reassessment are the keys to avoiding the complications of bladder outflow obstruction, which is the main objective and the real importance of managing BPH effectively.
All patients with BPH being managed in primary care are reviewed every 6–12 months, and continue their current course of management unless:
- They are on the watchful waiting course and deteriorate, in which case they are reviewed for an alternative management path
- Pharmacotherapy is shown to be ineffective, in which case hospital referral is made.
Figure 3 below shows the shared-care pathway.
|Figure 3: HIghcliffe urology clinic shared-care pathway|
Where there are absolute indications for surgery, or the patient has a high bother factor, TURP remains the gold standard treatment.
Around 35 000 TURP operations are carried out in the UK each year, with a morbidity of 17% and some mortality.15,16
After surgery, patients can be followed-up in the shared-care clinic.
NHS Beacon Award
The Highcliffe service has been shown to improve patient access to assessment and follow-up and to reduce inappropriate referrals to hospital. It was awarded NHS Beacon status in April 1999.
The TURP rate has reduced and the use of medical management and watchful waiting has increased.
The clinic has developed direct access to transrectal ultrasound (TRUS) and day-case flexible cystoscopy. Patients attending have expressed great satisfaction at the development of a local service.
The service is now available to eight practices in Dorset and Hampshire, representing 50 000 patients, and is aimed primarily at men aged >50 years with LUTS.
Over a 6-year period, around 1000 patients have undergone comprehensive urological assessment in their local community, with only 38% requiring hospital referral (Highcliffe registered patient data). With the development of flexible cystoscopy in the community, this figure could possibly be reduced to below 30%.
We believe that by bringing urological services nearer the patient through primary care, and achieving the outlined objectives, the incidence, prevalence and costs of acute and chronic urinary retention in the community can be reduced in the long term.
- Garraway WM, Collins GN, Lee RJ. High prevalence of benign prostatic hypertrophy in the community. Lancet 1991; 338: 469–71.
- Garraway WM, Russell EB, Lee RJ et al. Impact of previously unrecognized benign prostatic hyperplasia on the daily activities of middle-aged and elderly men. Br J Gen Pract 1993; 43: 318–21.
- Family Policy Studies Centre. Factsheet 1: Putting Families on the Map. London: Family Policy Studies Centre, 1994.
- Drummond MF, McGuire AJ, Black NA et al. Economic burden of treated benign prostatic hyperplasia in the United Kingdom. Br J Urol 1993; 71: 290-296.
- Kirby RS, Chisholm C, Chappel C et al. Shared care between general practitioners and urologists in the management of BPH. A survey of attitudes. J R Soc Med 1995; 88: 284P–8P.
- Hald T. Urodynamics in benign prostatic hyperplasia: a survey. Prostate 1989; 2 (Suppl): 69–77.
- Barry MV, Fowler FJ Jr, O'Leary MP et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol 1992; 148: 1549–57.
- Cockett AT et al. The 2nd international consultation on benign prostatic hyperplasia. Sci Commun Int 1994; 553-5.
- Lepor H, Williford WO, Barry MJ, Haakenson C, Jones K. The impact of medical therapy on bother due to symptoms, quality of life and global outcome and factors predicting response. Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group. J Urol 1998; 160: 1358–67.
- McConnell JD, Bruskewitz R, Walsh P et al. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. N Engl J Med 1998; 338 557-63.
- Craigen AA, Hickling JB, Saunders CR, Carpenter RG. Natural history of prostatic obstruction. J R Coll Gen Pract 1969; 18: 226–32.
- Ball AJ, Feneley RC, Abrams PH. The natural history of untreated 'prostatism'. Br J Urol 1981; 53: 613–16.
- Kadow C, Feneley RC, Abrams PH. Prostatectomy or conservative management in the treatment of benign prostatic hypertrophy. Br J Urol 1988; 61: 432–4
- Wasson JH, Reda DJ, Bruskewitz RC et al. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. N Engl J Med 1995; 332: 75–9.
- Doll HA, Black NA, McPhersson MC et al. Mortality, morbidity and complications following TURP for BPH (hypertrophy). J Urol 1992; 147: 1566–73.
- Thorpe AC, Cleary R, Coles J et al. Deaths and complications following prostatectomy in 1400 men in the Northern Regional Prostate Audit Group. Br J Urol 1994; 74: 559–65.
|The Association for Shared-Care Urology
The Association for Shared Care Urology (ASCU) was formed in 1998 to propagate discussion and develop high quality primary care strategies for health improvement.
ASCU aims to provide training, assessment and, when necessary, accreditation for any group wishing to develop new shared care urology services.
Further information and details of membership can be obtained from Mr GM Flannigan, Consultant Urologist and Honorary Secretary of ASCU (tel. 01274 364281; fax. 01274 366944).
NHS Beacon Awards
Beacon status is awarded to practices, trusts and other healthcare organisations within the NHS that have demonstrated good practice. The NHS Beacon programme aims to spread best practice across the health service. For further information visit the website: www.nhs.uk/beacons