Management of BPH in Patients with Impaired Renal Function
Surgery is recommended for patients who have renal insufficiency clearly due to BPH, as this approach addresses the underlying cause and can prevent further deterioration of renal function. 1
Diagnosis and Assessment
- Renal insufficiency due to BPH is uncommon but serious when it occurs, with baseline renal insufficiency appearing to be no more common in men with BPH than in men of the same age group in the general population 1
- Routine measurement of serum creatinine is not recommended in the initial evaluation of men with LUTS secondary to BPH unless there are specific risk factors 1
- The AUA Symptom Index should be used as the primary symptom-scoring instrument in the assessment of each patient presenting with BPH to quantify symptom severity 1
- Patients with BPH and impaired renal function should be evaluated for chronic urinary retention with large residual urine volumes (>300 ml), which is associated with renal insufficiency 2
Treatment Algorithm for BPH with Impaired Renal Function
First-line Treatment
- Surgical intervention is the recommended first-line treatment for patients with renal insufficiency clearly due to BPH 1, 3
- Transurethral Resection of the Prostate (TURP) remains the gold standard surgical treatment for BPH patients with renal insufficiency 3
- Open prostatectomy may be considered for patients with very large prostates 3
Alternative Surgical Options
- Transurethral Holmium Laser Resection/Enucleation provides complete removal of obstructing tissue with potentially fewer bleeding complications, which may be beneficial in patients with renal impairment 3
- Transurethral Laser Vaporization can be considered as an alternative surgical approach 3
Medical Management Considerations
- For patients who are not surgical candidates, treatment with intermittent catheterization, an indwelling catheter, or stent is recommended 1
- Alpha blockers may be used prior to attempted catheter removal in patients with urinary retention, with non-titratable options like tamsulosin or alfuzosin being preferable 1
- Tamsulosin does not require dose adjustment in renal impairment as active unbound drug levels are not affected despite increased total plasma concentration 4
- Finasteride is metabolized extensively in the liver with metabolites excreted in urine and feces, and no dosage adjustment is necessary in patients with renal impairment 5
Important Considerations and Monitoring
- Patients with renal transplants who develop BPH should be monitored closely as BPH can hinder recovery of the renal graft and may require surgical intervention 6
- Ureterovesicular junction obstruction from bladder remodeling in chronic urinary retention is a proposed mechanism for chronic renal failure in BPH patients 2
- Significant improvement in renal function has been observed after prostate surgery in patients with BPH-related renal insufficiency 2
- Balloon dilation is not recommended as a treatment option for patients with BPH, regardless of renal function 1, 3
Follow-up and Monitoring
- Patients who undergo surgical treatment for BPH with renal insufficiency should be monitored for improvement in renal function parameters 2
- Patients on medical therapy should be monitored for orthostatic hypotension, especially with the first dose of alpha blockers 7
- Regular assessment of renal function is important in patients with known renal impairment who are being managed for BPH 8
By following this evidence-based approach, clinicians can effectively manage BPH in patients with impaired renal function, potentially preventing further deterioration of renal function and improving quality of life.