Aktuelle Aspekte zur Epidemiologie, Diagnostik und Therapie des Benignen Prostatasyndroms

 

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Zusammenfassung

Hintergrund: Nach Veröffentlichung neuer nationaler und internationaler Leitlinien zur Diagnostik und Therapie des benignen Prostatasyndroms (BPS) wurde eine Neubewertung von etablierten Untersuchungen und Therapien vorgenommen. Dieser Artikel beschreibt die aktuellen Tendenzen und deren Stellenwert hinsichtlich Epidemiologie, Diagnostik und Therapie des BPS. Material und Methoden: Die Diagnostik- und Therapieleitlinien zum BPS der DGU, EAU, AUA, NICE wurden hinsichtlich Schlüsselartikel und neuesten Erkenntnissen analysiert. Ergebnisse: Die einzige deutsche epidemiologische Untersuchung zum BPS zeigte, dass alle Komponenten (Symptomatik, Prostatavergrößerung, Blasenauslassobstruktion) altersabhängig zunehmen. 27 % der deutschen Männer werden innerhalb von 5 Jahren eine Krankheitsprogres­sion haben. Risikofaktoren hierfür sind höheres Lebensalter, Symptomatik, Prostatavergrößerung bzw. PSA, Harnstrahlstärke und Restharn. Ziel der empfohlenen Diagnostik besteht in der Abgrenzung des BPS von anderen Erkrankungen mit ähnlicher Symptomatik, Quantifizierung der Teilkomponenten sowie Abschätzung des individuellen Progressionsrisikos. Das BPS wird durch keine Untersuchung direkt nachgewiesen, sondern ist eine Ausschlussdiagnose. Die Ultraschallmessung der Detrusordicke bei ≥ 250 ml ist eine Zusatzuntersuchung, die bei ≥ 2 mm sicher eine Blasenauslassobstruktion nachweist. Kontrolliertes Zuwarten und Verhaltenstherapie kommen für Männer mit milder Symptomatik und geringem Progressionsrisiko in Frage. Alle Medikamente reduzieren die Symptomatik, aber haben keinen Einfluss auf die Obstruktion. α-Blocker sind Medikamente der ersten Wahl und können bei irrita­tiven Symptomen mit Anticholinergika oder bei erhöhtem Progressionsrisiko mit 5α-Reduk­tase-Inhibitoren kombiniert werden. Die Kombinationstherapie ist effektiver als die Monotherapie. Bei Versagen der medikamentösen Therapie, absoluten Operationsindikationen oder starker Blasenauslassobstruktion sollte Prostatagewebe zur effektiven Beseitigung der Obstruktion abladiert werden. Standardoperationen sind die TURP bei geringem und die offene Adenomenukleation bei großem Prostatavolumen. Alternative operative Verfahren können bei ausgewählten Patienten eingesetzt werden und weisen Vorteile hinsichtlich Blutungsrisiko, Katheterliegedauer oder Sexualfunktion auf. Schlussfolgerungen: Aktuelle Leitlinien liefern eine effektive Grundlage zur verbesserten Abklärung und Behandlung von Patienten mit BPS. 

Abstract

Background: A re-evaluation of established tests and treatments has become necessary after publication of several new guidelines on BPH during the past two years. This article describes the latest developments concerning epidemiology, diagnosis, and treatment of BPH. Material and Methods: Diagnostic and treatment guidelines on BPH of the German, European, or North American urologists as well as UK doctors were reviewed according to key articles and latest modifications. Results: The only German epidemiological trial on BPH demonstrated that all components of the BPH disease (symptoms – prostate enlargement – bladder outlet obstruction) increase with ageing. 27 % of German men will have disease progression within the next 5 years. Risk factors for disease progression are: age, symptoms, prostate size, PSA, urinary flow rate, and postvoiding residual urine. Diagnosis aims to distinguish BPH from other diseases with similar symptoms, quantify the BPH components, and estimate the individual risk of disease progression. BPH is an exclusion diagnosis. Ultrasonic measurement of detrusor wall thickness at the anterior wall of bladders filled with ≥250 mL can securely detect bladder outlet obstruction if the value is ≥ 2 mm. Watchful waiting and lifestyle modifications are suitable for men with mild symptoms and low disease progression risk. All drugs used in BPH treatment reduce symptoms but have no influence on bladder outlet obstruction. α-blockers are first-line drugs and may be combined with muscarinic receptor antagonists or 5α-reductase inhibitors to further increase efficacy. Prostate surgery is indicated when drug treatment is insufficient, the patient develops complications in the upper or lower urinary tract (absolute indications), or has severe bladder outlet obstruction. Standard operations are TURP in small (≤ 80 mL) or open prostatectomy in large prostates (> 80 mL). Minimally invasive, alter­native surgeries may be considered in selected men and ­offer advantages with regard to the risk of bleeding, duration of catheterisation, or maintenance of sexual function. Conclusions: Current guidelines have integrated the latest knowledge and developments on BPH and are likely to improve assessment and treatment. 

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Privatdozent Dr. med. M. Oelke

Klinik für Urologie und Urologische Onkologie · Medizinische Hochschule Hannover

Carl-Neuberg-Str. 1

30625 Hannover

Email: oelke.matthias@mh-hannover.de

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