| ||||||||||||||||||||||||||||||||||||||||||||||||||
Benign prostatic hypertrophy
General Practitioner, Leeds
E-mail: will.bolland{at}doctors.org.uk
 |
Abstract |
|---|
TOP
Abstract
The RCGP curriculum and...The prevalence of symptomatic benign prostatic hypertrophy (BPH) in Europe varies from 14% for men in their fourth decade to more than 40% in their sixth. Assuming an overall prevalence of symptomatic BPH of 30%, in the UK, would mean that approximately 4 million men aged more than 40 years suffer from the condition.
Benign prostatic hypertrophy (BPH) is part of Gender-Specific Heath Issues—Men's Health, section 10.2, of the GP curriculum. Table 1 summarizes the learning objectives for the Men's Health curriculum that relate to the topics of BPH and prostate cancer.
|
|
|
|
Definition |
|---|
BPH is defined on the basis of clinical and histological findings:
- Histologically as proliferation of glandular epithelium, stroma, and smooth muscle of the prostate.
- Clinically as lower urinary tract symptoms (LUTS) presumed to be due to BPH. This has also been referred to as prostatism.
|
Aetiology |
|---|
The cause of BPH is not fully known, but ageing and long-term exposure to testosterone and particularly dihydrotestosterone are recognized as important factors. LUTS are classified as obstructive (or voiding) and irritative (or filling).
Obstructive (or voiding)Urinary Symptoms include:
- Hesitancy in initiating voiding
- Slow, intermittent or weak urinary stream
- Straining to void
- Terminal dribbling
- Sensation of incomplete emptying
- Double voiding (the need to void again soon after urinating)
Irritative (or filling) urinary symptoms include:
- Nocturia
- Day-time frequency
- Urgency
- Urge incontinence
|
Prognosis |
|---|
Studies suggest that most cases of BPH progress very slowly, but in some, symptoms can improve spontaneously. The Medical Therapy of Prostatic Symptoms trial, a large randomized controlled trial, with 737 men in the placebo arm and a mean follow-up of 4.5 years, showed progression (increase in symptom score of 4 or more development of complications) in 17% of men receiving placebo. Most cases of progression were due to symptom score changes, not complications. The study also showed the annual risk, in untreated BPH sufferers, of developing acute urinary retention (AUR) was 0.6%. BPH is not associated with an increased risk of prostate cancer, and the presence of LUTS has no predictive value for the presence of prostate cancer.
| Complications 10% of men with BPH will present with evidence of complications:
|
|
Assessment |
|---|
In all patients, in addition to assessing their LUTS, the presence or absence of erectile dysfunction should be ascertained, and the patient's health beliefs and concerns regarding prostate cancer and prostate-specific antigen (PSA) testing should be explored.
It is important to remember that male patients may be less articulate regarding their health than female patients. The interplay of gender, socio-economic status and cultural background can create very different health beliefs and attitudes and expectations of the doctor. It is important to try and ascertain whether the patient would prefer a same sex doctor and to try and arrange this where practical. To minimize embarrassment a caring, non-judgemental and professional consulting style should be adopted. Remember that men tend to consult less frequently and tend to have more illness, so have a lower threshold for suspecting a significant or serious disorder. Likewise, be mindful of other common conditions affecting men of a particular age, socio-economic status or cultural background, use the opportunity to screen for conditions that may co-exist and provide appropriate health education and promotion.
Assessment of BPH
The presence of LUTS can be ascertained from history and quantified using the International Prostate Symptom Score (IPSS) (Table 3). Further, practice-based examination and investigation are not diagnostic of BPH and serve only to exclude alternative causes of LUTS and detect possible complications of BPH.
|
|
The International Prostate Symptom Score (IPSS) |
|---|
The IPSS (Table 3) is not a diagnostic tool, but allows LUTS (Table 4) to be objectively and reproducibly graded as mild, moderate or severe. It is valuable for assessing the impact of urinary symptoms on the individual and monitoring progress and response to treatment.
|
|
GP management |
|---|
The goals of any management strategy should be:
- To allow men to make informed choices about treatment
- To reduce symptoms and improve quality of life
- To prevent complications (e.g. AUR)
- To minimize adverse effects of treatment
Possible management strategies are summarised in Table 5. The patient's preferences should be the key determinant in choosing a management strategy. In order to facilitate an informed decision, a full discuss of prognosis and the available treatment strategies should be made.
|
As LUTS/BPH and the available treatments are associated with sexual dysfunction, an assessment for sexual function should be made before starting treatment. Symptoms of sexual dysfunction associated with LUTS/BPH include the following: erectile dysfunction, pain/discomfort on ejaculation, and reduced ejaculate. Once pre-treatment sexual functioning is known, help can be provided where needed and any potential adverse effects arising from treatment of BPH can be detected and monitored with greater ease.
Inherent to good clinical practice, the identification and minimizing of aggravating factors should be carried out, where possible, before initiating treatment. Factors that may aggravate LUTS include:
- Medications (see differential diagnosis above)
- Alcohol and caffeine consumption
- Constipation
- Issues with mobility, manual dexterity or mental state that may hamper coping with LUTS.
As with all chronic conditions, learning coping strategies is central to a patient's experience of living with their condition. In BPH, a significant proportion of patients may be able manage their condition by coping strategies alone, without having to resort to medical or surgical intervention.
Advice on how to cope with urinary symptoms should include:
- Anticipate times when urinary frequency and urgency are likely to be most inconvenient (e.g. when going out) and reduce fluid intake beforehand. However, total daily fluid intake (about 1.5 litres) should not be reduced.
- Reduce evening fluid intake.
- Avoid constipation.
- Reduce or avoid consumption of caffeine and alcohol, which can aggravate frequency, urgency and nocturia.
- Relax when initiating urination.
- Void twice to ensure that the bladder is emptied completely.
- Control urgency by practising distraction techniques such as breathing exercises and mental tricks to take the mind off the bladder.
- Try retraining the bladder by ‘holding on’ and increasing the intervals between emptying the bladder.
|
When to refer |
|---|
As is evident from the list of strategies, most men with LUTS can be managed in primary care. So, when should you refer to a urology service? Local guidelines and protocols may vary, however, the National Institute for Health and Clinical Excellence (NICE) has published guidance to facilitate the development of these protocols. Tables 6 and 7 summarises the referral criteria.
|
|
|
Conventional drug therapy |
|---|
-Adrenoceptor agonistsAlpha-blockers are the usual first choice drug treatment for men with moderate/severe LUTS. They are shown to reduce symptoms, but do not slow the progression of BPH or reduce the risk of complications. They are thought to work by relaxing smooth muscle in the prostate and bladder neck. They only modestly improve urinary flow rate by 16–25%, but reduce symptom scores by 30–40%.
A total of 60–93% of men will experience improvement in symptoms of BPH with an alpha-blocker. In terms of effectiveness, there is no strong evidence for superiority of one alpha-blocker over another. Alpha-blockers begin to noticeably reduce symptoms of BPH within 2 weeks, so treatment response can be assessed quickly. The full effect can take up to 4–6 weeks.
If a man has little or no apparent benefit with an alpha-blocker, try increasing the dose of alpha-blocker or try adding a 5-alpha reductase inhibitor if the prostate is large. In terms of effectiveness, a man is unlikely to benefit from an alternative drug in the same class. Alpha-blockers available in the UK for men with BPH include alfuzosin, doxazosin, prazosin, tamsulosin or terazosin. As alpha-blockers are all similarly effective in relieving LUTS, the choice between alpha-blockers should be based on issues of safety, ease of administration and cost.
Adverse effects are usually minor and mainly of a vasodilatory (e.g. dizziness and first-dose hypotension) or central nervous system type (e.g. drowsiness and depressed mood). They tend to be dose related and are often either tolerated or disappear with continued use. Alpha-blockers are best taken at bedtime, especially when initiating, as there is a risk of first-dose and postural hypotension, especially in the elderly and those already on anti-hypertensives. Modified-release alfuzosin and doxazosin and tamsulosin have been reported as having less vasodilatory-type adverse effects than standard-release preparations. Modified-release formulations do not require dose titration. Do not use alpha-blockers in men with a known history of postural hypotension, micturition syncope (except tamsulosin) and urinary incontinence. Do not use modified-release doxazosin tablets in people with gastro-intestinal obstruction, oesophageal obstruction or any degree of stricture, as the outer membrane of the formulation is not digested. In men with ejaculatory problems, tamsulosin is best avoided as there is a higher risk of ejaculatory dysfunction than with other alpha-blockers. In people with a history of depression, use prazosin with caution, as this has been known to cause depression. In men on combination therapy, expert opinion is that the alpha-blocker should be stopped after 6 months, except in men with severe symptoms and for whom surgery would be undesirable.
|
5-Alpha reductase inhibitors |
|---|
5-Alpha reductase inhibitors block conversion of testosterone into the more potent dihydrotestosterone. This leads to a modest reduction in prostate size (up to 30%), with possible improvement in urinary flow rate and in obstructive symptoms. A systematic review of the literature, concluded that long-term use of 5-alpha reductase inhibitors:
- Reduces the size of the prostate gland by 20–30%
- Moderately improves urine flow by about 1.3–1.6 ml/s
- Reduces symptom scores by
15% (note: less than half the reduction achieved by alpha-blockers)
- Reduces the incidence of AUR
- Reduces the need for surgical intervention
- Reduces the risk of AUR more in men with greater prostate volumes and/or higher serum PSA levels
5-Alpha reductase inhibitors are unlikely to benefit men who do not have enlarged prostates. They are indicated for men with enlarged prostates, to minimize the risk of clinical progression. They can be used either in combination with an alpha-blocker or alone (where there has been no response to an alpha-blocker or where adverse effects of alpha-blockers have not been tolerated).
Two 5-alpha reductase inhibitors are available in the UK, finasteride and dutasteride. Only finasteride is specifically licensed for use in combination with doxazosin for BPH but it seems reasonable to combine either 5-alpha reductase inhibitor with any alpha-blocker.
Improvement in symptoms will occur in most men 3–6 months after initiation. Symptomatic improvement while on treatment is maintained for at least 6 years. Therefore, if clinical benefit is apparent after 6 months of use, treatment should be continued long term.
5-Alpha reductase inhibitors are well tolerated—people experience less adverse effects than with alpha-blockers. Sexual adverse effects including decreased libido, ejaculation disorder and erectile dysfunction occur in 6–8% men; this increased incidence tends to occur only during the first year of therapy and decreases with duration of treatment. Women of childbearing potential are advised to handle finasteride and dutasteride formulations with care, and use of a condom is recommended where a partner is taking either of these drugs, to avoid a very slight chance of foetal abnormalities to male genitalia. PSA concentrations are roughly halved by 5-alpha reductase inhibitors and should be multiplied by 2 for comparison with reference values.
|
Surgical treatment |
|---|
Compared with watchful waiting and drug treatments surgical treatment is more effective for relieving symptoms but has higher complication rates.
Transurethral resection of the prostate (TURP) is the reference surgical treatment for BPH. Open prostatectomy is now seldom performed for BPH. Following surgical therapy, symptom scores can be expected to improve by 15–20 points and the maximum urine flow rate by 10 ml/second. TURP originally involved a stay in hospital of 2–5 days, but with newer technologies, it can now be performed as day-case surgery in selected cases. Complications of TURP are summarised in Table 8.
|
Minimally invasive alternatives to TURP
A number of minimally invasive procedures have been developed as an alternative to TURP, with the aim of reducing the risk of complications and length of hospital stay (many can be carried out as day-case surgery).
NICE has approved a number of minimally invasive procedures:
- Holmium laser prostatectomy.
- Potassium-titanyl-phosphate laser vaporization of the prostate.
- Transurethral electrovaporization of the prostate.
- Transurethral radiofrequency needle ablation of the prostate.
The NICE summary found that there is evidence that these new minimally invasive procedures are less likely to cause complications compared with TURP, in particular those of sexual dysfunction and incontinence. However, they have been compared with TURP in few trials, with small numbers of participants, and follow-up has not been long enough to provide good evidence on long-term outcomes. There is insufficient evidence to prefer any one minimally invasive procedure over another.
|
Herbal remedies |
|---|
There is no good evidence of effectiveness and no evidence of long-term safety for any herbal preparation used to treat BPH. Popular herbal therapies (also called phytotherapies) include:
- Saw palmetto (Serenoa repens)—extracts from fruit of the American dwarf palm.
- Beta sitosterol—plant extracts.
- Rye grass (Secale cereale)—pollen extracts.
- Pygeum africanum—bark extract.
Studies of herbal preparations suffer from methodological problems such as inadequate outcome measures, no direct comparison with other active treatments, short study periods, non-standard preparations and little evidence of safety, especially with chronic use.
Saw palmetto is used by over 2 million men in the United States for the treatment of BPH. It has been suggested that the evidence for clinical benefit of saw palmetto is limited but better than that for other herbal therapies. However, a recent double blind randomized controlled trial failed to find any symptomatic or objective benefit for saw palmetto used over 1 year to treat moderate to severe LUTS due to BPH.
Key points
|
|
References |
|---|
-
American Urological Association. Guideline on the management of benign prostatic hyperplasia (BPH) (2003) American Urological Association. Accessed via www.auanet.org/guidelines/main_reports/bph_management/preface_toc.pdf [date last accessed 09.09.2008].
Baldwin KC, Ginsberg PC, Roehrborn CG, Harkaway RC. Discontinuation of alpha-blockade after initial treatment with finasteride and doxazosin in men with lower urinary tract symptoms and clinical evidence of benign prostatic hyperplasia. Urology (2001) 58(2):203–9.[CrossRef][Web of Science][Medline]
Barkin J, Guimaraes M, Jacobi G, et al. Alpha-blocker therapy can be withdrawn in the majority of men following initial combination therapy with the dual 5 alpha-reductase inhibitor dutasteride. European Urology (2003) 44(4):461–6.[CrossRef][Web of Science][Medline]
Barry MJ, Fowler FJ, O’Leary MP, et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. Journal of Urology (1992) 148(5):1549–57.[Web of Science][Medline]
Bent S, Kane C, Shinohara K, et al. Saw palmetto for benign prostatic hyperplasia. New England Journal of Medicine (2006) 354(6):557–66.
Clinical Knowledge Summaries (CKS). Prostate—Benign Hyperplasia (2006) National Library for Health. Accessed via www.cks.library.nhs.uk/prostate_benign_hyperplasia [date last accessed 12.06.2008].
Crawford ED. Management of lower urinary tract symptoms suggestive of benign prostatic hyperplasia: the central role of the patient risk profile. BJU International (2005) 95((suppl 4)):1–5.[Web of Science][Medline]
De la Rosette J, Madersbacher S, Alivizatos G, et al. Guidelines on benign prostatic hyperplasia. European Association of Urology (2004)).
Djavan B, Marberger M. A meta-analysis on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction. European Urology (1999) 36(1):1–13.[Web of Science][Medline]
Edwards JE, Moore RA. Finasteride in the treatment of clinical benign prostatic hyperplasia: a systematic review of randomised trials. BMC Urology (2002) 2(1):14.[CrossRef][Medline]
Ekman P. Maximum efficacy of finasteride is obtained within 6 months and maintained over 6 years. Follow-up of the Scandinavian Open-Extension Study. The Scandinavian Finasteride Study Group. European Urology (1998) 33(3):312–7.[CrossRef][Web of Science][Medline]
Engstrom G, Walker-Engstrom ML, Henningsohn L, et al. Prevalence of distress and symptom severity from the lower urinary tract in men: a population-based study with the DAN-PSS questionnaire. Family Practice (2004) 21(6):617–22.
Ishani A, MacDonald R, Nelson D, et al. Pygeum africanum for the treatment of patients with benign prostatic hyperplasia: a systematic review and quantitative meta-analysis. American Journal of Medicine (2000) 109(8):654–64.[CrossRef][Web of Science][Medline]
Kaplan SA, Volpe MA, Te AE. A prospective, 1-year trial using saw palmetto versus finasteride in the treatment of category III prostatitis/chronic pelvic pain syndrome. Journal of Urology (2004) 171(1):284–8.[CrossRef][Web of Science][Medline]
Klimberg IW, Locke DR, Leonard E, et al. Outpatient transurethral resection of the prostate at a urological ambulatory surgery center. Journal of Urology (1994) 151(6):1547–9.[Web of Science][Medline]
Lepor H, Williford WO, Barry MJ, et al. The efficacy of terazosin, finasteride, or both in benign prostatic hyperplasia. Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group. New England Journal of Medicine (1996) 335(8):533–9.
Lowe FC. Treatment of lower urinary tract symptoms suggestive of benign prostatic hyperplasia: sexual function. BJU International (2005) 95((suppl 4)):12–8.[CrossRef][Medline]
Madersbacher S, Alivizatos G, Nordling J, et al. EAU 2004 guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms suggestive of benign prostatic obstruction (BPH guidelines). European Urology (2004) 46(5):547–54.[CrossRef][Web of Science][Medline]
McConnell JD, Roehrborn CG, Bautista OM, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. New England Journal of Medicine (2003) 349(25):2387–98.
Micromedex (2005) MICROMEDEX [CD-ROM]. (Volume 124, 2nd quarter 2005). Thomson Healthcare.
NHS Cancer Screening Programme. Prostate Cancer Risk Management: Patient Informaton Sheet. Available from www.cancerscreening.nhs.uk/prostate/prostate-patient-info-sheet.pdf [date last accessed 09.09.2008].
NHS Cancer Screening Programme. Prostate Cancer Risk Management: Reference Booklet. Available from www.cancerscreening.nhs.uk/prostate/prostate-booklet-text.pdf [date last accessed 09.09.2008].
NICE. Referral advice—a guide to appropriate referral from general to specialist services (2001) National Institute for Health and Clinical Excellence. Accessed via www.nice.org.uk/newsevents/pressreleases/pressreleasearchive/pressreleases2001/2001_043__nice_issues_advice_on_appropriate_referral_from_general_to_specialist_services.jsp [date last accessed 10.08.2008].
NICE. Transurethral electrovaporisation of the prostate. Interventional procedure guidance 14 (2003a) National Institute for Health and Clinical Excellence. Accessed via www.nice.org.uk/nicemedia/pdf/ip/IPG014guidance.pdf [date last accessed 10.08.2008].
NICE. Transurethral radiofrequency needle ablation of prostate. Interventional procedure guidance 15 (2003b) National Institute for Health and Clinical Excellence. Accessed via www.nice.org.uk/nicemedia/pdf/ip/ipg015guidance.pdf [date last accessed 10.08.2008].
NICE. Holmium laser prostatectomy. Interventional procedure guidance 17 (2003c) National Institute for Health and Clinical Excellence. Accessed via www.nice.org.uk/nicemedia/pdf/ip/ipg017guidance.pdf [date last accessed 10.08.2008].
NICE. Potassium-titanyl-phosphate (KTP) laser vaporisation of the prostate for benign prostatic obstruction. Interventional procedure guidance 120 (2005a) National Institute for Health and Clinical Excellence. Accessed via www.nice.org.uk/nicemedia/pdf/ip/IPG120guidance.pdf [date last accessed 10.08.2008].
NICE. Referral guidelines for suspected cancer: quick reference guide. Clinical guideline 27 (2005b) National Institute for Health and Clinical Excellence. Accessed via www.nice.org.uk/Guidance/CG27 [date last accessed 10.08.2008].
Nickel JC, Elhilali M, Vallancien G, ALF-ONE Study Group. Benign prostatic hyperplasia (BPH) and prostatitis: prevalence of painful ejaculation in men with clinical BPH. BJU International (2005) 95(4):571–4.[CrossRef][Web of Science][Medline]
Royal College of General Practitioners. Men's Health, Curriculum Statement 10.2 (2007) Accessed via www.rcgp-curriculum.org.uk/PDF/curr_10_2_Mens_health.pdf [date last accessed 29.05.2008].
Sagalowski AL, Wilson JD. Hyperplasia and carcinoma of the prostate. In: Harrison's principles of internal medicine—Fauci AS, Longo D, eds. ((1998) 14th edn. New York: McGraw-Hill, 1–10.
Speakman MJ, Kirby RS, Joyce A, et al. Guideline for the primary care management of male lower urinary tract symptoms. BJU International (2004) 93(7):985–90.[CrossRef][Web of Science][Medline]
Vallancien G, Emberton M, Harving N, et al. Sexual dysfunction in 1274 European men suffering from lower urinary tract symptoms. Journal of Urology (2003) 169(6):2257–61.[CrossRef][Web of Science][Medline]
Webber R. Benign prostatic hyperplasia. BMJ Clinical Evidence (2004) BMJ Publishing Group Ltd. Accessed via www.clinicalevidence.com [date last accessed 14.05.2008].
Wessells H, Roy J, Bannow J, et al. Incidence and severity of sexual adverse experiences in finasteride and placebo-treated men with benign prostatic hyperplasia. Urology (2003) 61(3):579–84.[CrossRef][Web of Science][Medline]
Wilt T, Mac Donald R, Ishani A, et al. Cernilton for benign prostatic hyperplasia (Cochrane Review). The Cochrane Library. (1998) (Issue 3 ). John Wiley & Sons, Ltd. Accessed via www.thecochranelibrary.com [date last accessed 03.06.2008].
Wilt T, Ishani A, Mac DR, et al. Beta-sitosterols for benign prostatic hyperplasia (Cochrane Review). The Cochrane Library. (1999) (Issue 3 ). John Wiley & Sons, Ltd. Accessed via www.thecochranelibrary.com [date last accessed 03.06.2008].
Wilt TJ, Ishani A, Rutks I, MacDonald R. Phytotherapy for benign prostatic hyperplasia. Public Health Nutrition (2000) 3(4A):459–72.[Medline]
Wilt TJ, Mac Donald R, Rutks I. Tamsulosin for benign prostatic hyperplasia (Cochrane Review). The Cochrane Library. (2002a) (Issue 4 ). John Wiley & Sons, Ltd. Accessed via www.thecochranelibrary.com [date last accessed 03.06.2008].
Wilt T, Ishani A, Mac Donald R. Serenoa repens for benign prostatic hyperplasia (Cochrane Review). The Cochrane Library. (2002b) (Issue 3 ). John Wiley & Sons, Ltd. Accessed via www.thecochranelibrary.com [date last accessed 03/06/2008].
Wilt TJ, Howe W, MacDonald R. Terazosin for treating symptomatic benign prostatic obstruction: a systematic review of efficacy and adverse effects. BJU International (2002c) 89(3):214–25.[CrossRef][Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||