**7. Treatment**

Patients with mild symptoms are most appropriately managed by watchful waiting, patients with moderate symptoms should receive pharmacotherapy and patients with severe bother most benefit from surgical management. A man with preoperative IPSS ≥ 17 has an 87% chance of experiencing a substantial symptom reduction (Meigs, Mohr et al. 2001).

A group of patients at increased risk of progression can be identified on the basis of specific risk factors (e.g. age, symptoms, PSA level, Qmax, prostate volume and post-void residual urine). It might be appropriate to identify these patients at risk of progression and initiate early preventative treatment (Emberton et al., 2003)(Gabuev and Oelke 2011). For example, a higher frequency of kidney failure in patients presenting for prostate surgery than for nonprostate surgery has been shown, and several studies have shown improvement in kidney function after prostatectomy (Hill et al., 1993).

### **7.1 Acute treatment**

Patients who present to the emergency department with bladder outlet obstruction and high serum creatinine should receive a urethral catheter and subsequently evaluated in order to distinguish between acute and chronic renal failure. Hospitalization is often required in these cases. If ureterohydronephrosis and azotaemia persists despite bladder desobstruction, an ureterovesical junction obstruction should be considered and bilateral percutaneous nephrostomy or bilateral ureteric stents (if feasible) are advisable for temporarily drainage. Patients may need urgent and transitory dialysis.

Neoureterocystostomy after a prostate ablative procedure may be adequate for definite ureterovesical junction obstruction resolution.

### **7.2 Watchful waiting**

Watchful waiting (WW) is an appropriate strategy for men who are not bothered by their symptoms and have not developed BPH related complications.

This option should include education, reassurance, periodic monitoring and lifestyle advice to the patient. Lifestyle counseling include: reduction of fluid intake during specific times for control of urinary frequency (e.g. at night or when going out in public) but not of the total amount of daily fluid (above 1500 mL per day), avoidance of alcohol and caffeine because they have diuretic and irritant effect, bladder retraining to increase its capacity and constipation treatment. Watchful waiting is based on the notion that some symptoms may spontaneously improve whilst others may remain stable for years. The PSA level and the prostate volume may be helpful in predicting the risk of acute urinary retention, although they should not be used as a sole determinant for active therapy (Levy and Samraj 2007). Approximately 85% of men will be stable on WW at 1 year, deteriorating progressively to 65% at 5 years (Wasson, Reda et al. 1995; Netto, de Lima et al. 1999). This approach is not suitable for men with installed CKD due to bladder outlet obstruction.
