Who Manages Prostate Issues
Urologists are the primary specialists who manage prostate conditions including BPH, prostatitis, and prostate cancer, though primary care physicians can and should manage uncomplicated BPH cases with appropriate patient selection. 1
Primary Care Physician Role in BPH Management
Primary care physicians can effectively manage mild to moderate BPH without evidence of prostate cancer in their practice setting. 2 This represents a shift from the traditional model where urologists served as first-line physicians for all prostate issues. 2
Appropriate Cases for Primary Care Management:
- Men over age 50 with lower urinary tract symptoms (LUTS) attributed to BPH 1
- Patients with mild to moderate symptoms without complications 1
- Those suitable for watchful waiting or medical therapy 1
- Patients without significant risk factors for non-BPH causes of LUTS (no polyuria, underlying neurologic disease, or prior lower urinary tract disease) 1
Initial Evaluation by Primary Care:
- Medical history including symptom severity, duration, bother level, prior treatments, and family history of prostate disease 1
- Digital rectal examination (DRE) to exclude locally advanced prostate cancer and assess prostate size 1
- Focused neurologic examination assessing mental status, ambulatory status, lower extremity function, and anal sphincter tone 1
- Urinalysis by dipstick or microscopic examination to screen for hematuria and urinary tract infection 1
- PSA measurement in select patients: those with at least 10-year life expectancy where cancer detection would change management, or when PSA may influence BPH treatment decisions 1
Medical Management by Primary Care:
- Alpha-blockers as first-line therapy for symptomatic BPH 3
- 5-alpha-reductase inhibitors for patients with demonstrable prostatic enlargement 3
- Primary care physicians prescribed alpha-blockers to a median of 12 patients and finasteride to a median of 2 patients annually 4
Mandatory Urologist Referral Situations
Refer to urology for any of the following:
Absolute Indications:
- Suspected or confirmed prostate cancer requiring staging, biopsy, or treatment 5, 6
- Acute urinary retention 1
- Renal insufficiency secondary to BPH 1
- Recurrent urinary tract infections 1
- Bladder stones 1
- Gross hematuria requiring cystoscopy 1
- History of urolithiasis or prior urinary tract surgery 1
Relative Indications:
- Moderate to severe symptoms that have failed medical therapy 3
- Patients desiring surgical or minimally invasive treatment options 1
- Predominantly irritative symptoms requiring cystoscopy and possible urine cytology 1
- Younger men (under 50) with voiding dysfunction 1
- Underlying neurologic disease affecting voiding 1
Shared Care Model
A collaborative "shared care" approach between primary care physicians and urologists represents the optimal model for managing BPH patients. 2 This model centers on effective patient education and communication about BPH, with primary care managing uncomplicated cases and urologists handling complex cases, surgical interventions, and cancer management. 2, 5
Urologist-Specific Expertise:
- Surgical management including transurethral resection of the prostate (TURP), which remains the benchmark therapy 1
- Minimally invasive procedures such as transurethral microwave therapy (TUMT) 1
- Prostate cancer diagnosis, staging, and treatment including radical prostatectomy 5, 6
- Cystoscopy for diagnostic evaluation 1
- Management of BPH complications 7
Practice Pattern Considerations
Primary care physicians see substantially fewer BPH patients than urologists (median 35 vs. 240 patients annually), which may affect diagnostic and treatment patterns. 4, 6 Primary care physicians show variation in adherence to guideline recommendations, particularly regarding use of AUA symptom indices (two-thirds rarely or never use them) and optional testing. 4
Common pitfall: Primary care physicians often order tests "not recommended" by guidelines, with 34% routinely ordering intravenous pyelography and 33% ordering renal ultrasound without appropriate indications. 4 These should be reserved for patients with hematuria, UTI, renal insufficiency, or history of urolithiasis. 1