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.
Schlüsselwörter
benignes Prostatasyndrom - Symptome des unteren Harntraktes - Risikoabklärung - Diagnose
- Therapie
Key words
benign prostatic hyperplasia - lower urinary tract symptoms - risk assessment - diagnosis
- therapy
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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
