Treatment
Goals
Because BPH is not often life-threatening, the focus of treatment has typically been to alleviate bothersome LUTS and other symptoms. With advances in treatment, additional goals include the alteration of disease progression and the prevention of associated complications such as recurrent urinary tract infections, hematuria, or acute urinary retention, particularly in men with an enlarged prostate (ie, volume >30 mL or PSA >1.5 ng/mL), since disease progression is more likely in these patients.17,19 A recent Medline-based systematic review reported that men prefer therapies that affect long-term progression over therapies that provide short-term symptom improvement.20 These results were consistent with those from a 2006 survey of 400 men with an enlarged prostate, which also reported that men are generally willing to wait up to 3 months for symptom relief if treatment would resolve the underlying condition.21 It is, therefore, important to discuss with the patient the natural history of BPH and its complications, and the benefits and risks of currently available noninvasive and invasive treatment options.
Options
Treatment options for BPH are watchful waiting, lifestyle and behavioral management, pharmacologic therapy, and surgical intervention. Many men use phytobotannical therapy such as saw palmetto, African plum tree, pumpkin seed, rye pollen, stinging nettle, South African star grass, and quercetin to relieve LUTS, although investigations regarding their use are often of poor quality. Saw palmetto is the best studied, yet a Cochrane review found few high-quality studies. The authors of the review concluded that saw palmetto was not more effective than placebo for treatment of LUTS.22 Similar results were observed in a randomized, double-blind, placebo-controlled trial more recently published by the Complementary and Alternative Medicine for Urological Symptoms (CAMUS) Study Group.23
Watchful waiting is appropriate when only LUTS are present, with or without some degree of nonsuspicious prostate enlargement, and the symptoms are not particularly bothersome to the patient or if the patient does not want treatment.19 Lifestyle management and behavioral modification should generally be used in combination with other treatment options in an effort to alleviate symptoms, especially in men in whom storage symptoms predominate. Lifestyle management may include reducing fluid intake (particularly if polyuria is present), increasing physical activity, achieving a normal weight, timed voiding (bladder retraining), pelvic floor exercises, treatment for constipation, and avoidance of irritative foods and beverages.17,19 Epidemiologic evidence over 7 years of surveillance suggests that a diet low in fat and red meat and high in protein and vegetables, as well as regular alcohol consumption (>1 drink/month), may reduce the risk of symptomatic BPH.24 Evidence was weak concerning the benefits of lycopene, zinc, and supplemental vitamin D. No dietary supplement, combination phytotherapeutic agent, or other nonconventional therapy is recommended by the American Urological Association (AUA) for the management of LUTS secondary to BPH.19
Surgical intervention is considered appropriate in patients with moderate to severe LUTS in whom other medical therapies have not achieved treatment goals and in those in whom benign prostatic obstruction has led to complications such as renal insufficiency, urinary retention, recurrent urinary tract infections, bladder calculi, or hydronephrosis. Patients in whom surgical intervention is contemplated should be referred to a urologist.17,19
Pharmacologic Options
Three classes of pharmacologic agents have been approved by the US Food and Drug Administration (FDA) for the treatment of symptomatic BPH: AABs, 5-ARIs, and PDE-5Is. The AABs include alfuzosin, doxazosin, silodosin, tamsulosin, and terazosin, and target the dynamic (smooth muscle tone) component of BPH-induced bladder outlet obstruction. The 5-ARIs finasteride and dutasteride target the static (prostate mass) component of BPH-induced bladder outlet obstruction. The PDE-5Is (ie, sildenafil, tadalafil, and vardenafil) increase the amount of cyclic guanosine monophosphate in the smooth muscle of the corpus cavernosum, prostate, and bladder.
Alpha1-Adrenergic Blockers. The four older AABs (ie, alfuzosin, doxazosin, tamsulosin, and terazosin) have been extensively investigated in clinical trials and widely used in the management of BPH. A 2010 review by the AUA concluded that the minor efficacy differences reported among the 4 older AABs were not clinically significant.19 Although ejaculatory dysfunction may occur with the use of the AABs, these agents are generally well-tolerated, with dizziness the most common AE, occurring in 2% to 14% of men. Ejaculatory dysfunction may be a part of the disease process itself, as noted earlier.
The newest AAB, silodosin, at a dosage of 8 mg/d was reported to have efficacy similar to tamsulosin 0.2 to 0.4 mg/d in reducing storage and voiding LUTS in three 12-week trials.25-27 Silodosin has also been associated with a significant improvement in patients’ quality of life. The most frequent AE related to silodosin use was abnormal ejaculation, occurring in 10% to 22% and causing discontinuation in 1% to 3%.25-27 One 12-week study reported that systolic blood pressure (BP) decreased 0.1 and 4.2 mm Hg in the silodosin and tamsulosin groups, respectively.25 The negligible reduction in BP observed with silodosin is likely due to the selectivity of silodosin for the alpha1A-adrenergic receptor rather than the alpha1B-adrenergic receptor, the blockade of which reduces BP.