Benign prostatic hyperplasia: Treat or wait?

,

Applied Evidence

Benign prostatic hyperplasia: Treat or wait?

J Fam Pract. 2008 July;57(7):454-463

By

John H. Davidson, MD

Questionnaire with "bother score" can help you decide.

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References

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15. Madersbacher S, Alivizatos G, Nordling J, Sanz CR, Emberton M, de la Rosette JJ. EAU 2004 Guidelines on assessment, therapy and follow-up of men with lower urinary symptoms suggestive of benign prostatic obstruction (BPH Guidelines). Eur Urol. 2004;46:547-554.

16. Chapple CR, Roehrborn CG. A shifted paradigm for the further understanding, evaluation, and treatment of lower urinary tract symptoms in men: focus on the bladder. Eur Urol. 2006;49:651-659.

17. Knutson T, Edlund C, Fall M, Dahlstrand C. BPH with coexisting overactive bladder dysfunction—an everyday urological dilemma. Neurourol Urodyn. 2001;20:237-247.

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19. Roehrborn CG, McConnell JD, Bonilla J, Rosenblatt S, et al. Serum prostate-specific antigen is a strong predictor of future prostate growth in men with benign prostatic hyperplasia: PROSCAR long-term efficacy and safety study. J Urol. 2000;163:13-20.

20. Harris R, Lohr KN. Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:917-929.

21. Jones JS, Klein E. Four no more: the 'PSA cutoff era' is over. Cleve Clin J Med. 2008;75:30-32.

22. O'Leary MP. Lower urinary tract symptoms/benign prostatic hyperplasia: Maintaining symptom control and reducing complications. Urology. 2003;62(Suppl 3A):15-23.

23. Oesterling JE. Benign prostatic hyperplasia: medical and minimally invasive treatment options. N Engl J Med. 1995;332:99-109.

24. Weiss JP, Blaivas JG. Nocturia. J Urol. 2000;163:5-12.

25. Reynard JM, Cannon A, Yang Q, Abrams P. A novel therapy for nocturnal polyuria: a double-blind randomized trial of furosemide against placebo. Br J Urol. 1998;81:215-218.

26. Abrams P, Kaplan S, De Konig Gans HJ, Millard R. Safety and tolerability of tolterodine for the treatment of overactive bladder in men with bladder outlet obstruction. J Urol. 2006;175:999-1004.

27. Athanasopoulos A, Gyftopoulos K, Giannitsas K, Fisfis J, Perimenis P, Barbalias G. Combination treatment with an alpha-blocker plus an anticholinergic for bladder outlet obstruction: a prospective, randomized controlled study. J Urol. 2003;169:2253-2256

28. van Kerrebroeck P, Jardin A, Laval KU, van Cangh P. Efficacy and safety of a new prolonged release formulation of alfuzosin 10 mg once daily versus alfuzosin 2.5 mg thrice daily and placebo in patients with symptomatic benign prostatic hyperplasia. Eur Urol. 2000;7:306-313.

29. Mottet N, Bressolle F, Delmas V, Robert M, Costa P. Prostatic tissual distribution of alfuzosin in patients with benign prostatic hyperplasia following repeated oral administration. Eur Urol. 2003;44:101-105.

30. Beduschi MC, Beduschi R, Oesterling JE. Alpha-blockade therapy for benign prostatic hyperplasia: from a nonselective to a more selective alpha1A-adrenergic antagonist. Urology. 1998;51:861-872.

31. Lepor H, Auerbach S, Puras-Baez A, et al. A randomized, placebo-controlled multicenter study of the efficacy and safety of terazosin in the treatment of benign prostatic hyperplasia. J Urol. 1992;148:1467-1474.

32. McConnell JD, Roehrborn CG, Bautista OM, et at. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med. 2003;349:2387-2398.

33. Roehrborn CG. Efficacy and safety of once-daily alfuzosin in the treatment of lower urinary tract symptoms and clinical benign prostatic hyperplasia: a randomized, placebo-controlled trial. Urology. 2001;58:953-959.

34. Lepor H. Long-term evaluation of tamsulosin in benign prostatic hyperplasia: placebo-controlled, double-blind extension of phase III trial. Tamsulosin Investigator Group. Urology. 1998;51:901-906.

35. Clifford GM, Farmer RDT. Medical therapy for benign prostatic hyperplasia: a review of the literature. Eur Urol. 2000;38:2-19.

36. Thompson IM, Goodman PJ, Tangen CM, et al. The influence of finasteride on the development of prostate cancer. N Engl J Med. 2003;349:215-224.

37. Roehrborn CG. The clinical benefits of dutasteride treatment for LUTS and BPH. Rev Urol. 2004;6(Suppl 9):S22-SS30.

38. Roehrborn CG, Lukkarinen O, Mark S, Siami P, Ramsdell J, Zinner N. Long-term sustained improvement in symptoms of benign prostatic hyperplasia with the dual 5alpha-reductase inhibitor dutasteride: results of 4-year studies. BJU Int. 2005;96:572-577.

39. Edzard E. The risk-benefit profile of commonly used herbal therapies: ginkgo, St John's wort, ginseng, Echinacea, saw palmetto, and kava. Ann Intern Med. 2002;136:42-53.

40. Bent S, Kane C, Shinohara K, et al. Saw palmetto for benign prostatic hyperplasia. N Engl J Med. 2006;354:557-566.

41. Food and Drug Administration. ALFOTAM trial. Center for Drug Administration and Research. Available at: www.pbm.va.gov/criteria/Alpha-Blocker%20CFU%207-2005.pdf. Accessed November 16, 2006.

42. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg. 2005;31:664-673.

43. Uroxatral [package insert]. Bridgewater, NJ: Sanofi-Aventis U.S.; 2007.

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48. Kaplan SA, Roehrborn CG, Rovner ES, Carlsson M, Bavendam T, Guan Z. Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder: a randomized controlled trial. JAMA. 2006;296:2319-2328.Erratum in: JAMA 2007; 297:1195.

49. Healing Herbs and Natural Remedies. Available at: http://www.herbsandnaturalremedies.com/topsellers.htm. Accessed January 3, 2007.

50. Safarinejad MR. Urtica dioica for treatment of benign prostatic hyperplasia: a prospective, randomized, double-blind, placebo-controlled, crossover study. J Herb Pharmacother. 2005;5:1-11.

51. Wasson JH, Reda DJ, Bruskewitz RC, Elinson J, Keller AM, Henderson WG. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. N Engl J Med. 1995;332:75-79.

52. Hammadeh MY, Madaan S, Hines J, Philp T. 5-year outcome of a prospective randomized trial to compare transurethral electrovaporization of the prostate and standard transurethral resection. Urology. 2003;61:1166-1171.

53. Ahyai SA, Lehrich K, Kuntz RM. Holmium laser enucleation versus transurethral resection of the prostate: 3-year follow-up results of a randomized clinical trial. Eur Urol. 2007;52:1456-1464.

54. Kuntz RM. Laser treatment of benign prostatic hyperplasia. World J Urol. 2007;25:241-247.

55. Gupta N, Sivaramakrishna, Kumar R, Dogra PN, Seth A. Comparison of standard transurethral resection, transurethral vapour resection and holmium laser enucleation of the prostate for managing benign prostatic hyperplasia of >40 g. BJU Int. 2006;97:85-89.

56. Tan AH, Gilling PJ, Kennett KM, Frampton C, Westenberg AM, Fraundorfer MR. A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams). J Urol. 2003;170(4 Pt 1):1270-1274.

57. Zlotta AR, Giannakopoulos X, Maehlum O, Ostrem T, Schulman CC. Long-term evaluation of transurethral needle ablation of the prostate (TUNA) for treatment of symptomatic benign prostatic hyperplasia: clinical outcome up to five years from three centers. Eur Urol. 2003;44:89-93.

Practice recommendations

Talk to every male patient over the age of 50 about urinary function (C).
Utilize questionnaires, such as the International Prostate Symptom Score to evaluate the patient's perception of symptom severity and quality of life (A).
Rule out potential causes of lower urinary tract symptoms with a thorough medical history, focused physical exam (including digital rectal examination and neurological assessments), and appropriate laboratory evaluations (C).
When choosing treatment for benign prostatic hyperplasia, remember that quality of life is generally more important than symptom severity (A).

Strength of recommendation (SOR)

Good quality patient-oriented evidence
Inconsistent or limited-quality patient-oriented evidence
Consensus, usual practice, opinion, disease-oriented evidence, case series

"My wife is mad at me—and she's worried, too," says Dan, a 65-year-old patient of yours. "She's been telling me to come see you, but I've been putting it off.

"I've been getting up 4 and 5 times a night to urinate, and we can't drive an hour without me having to stop at least once to use a restroom."

With a deep sigh, Dan says: "My wife is worried that I have cancer or something."

"And I'm worried, too," he admits.

Benign prostatic hyperplasia (BPH), and its clinical expression as lower urinary tract symptoms—urinary frequency, urgency, nocturia, decreased force of stream, and incomplete bladder emptying—comprise a major health concern for many older men. Approximately 50% of men over age 60 have at least microscopic BPH, while 90% over age 90 have evidence of the abnormality.¹

Many men fail to seek help for lower urinary tract symptoms associated with BPH,^2-4 even though these often moderate to severe symptoms are associated with decreased quality of life, anxiety, and depression.⁵ Your patient may be uncomfortable broaching the subject, as Dan was, for fear that he may have cancer. He may dismiss the symptoms as a natural consequence of aging,⁶ or he may believe that there are no effective treatments or that treatment will cause unwanted side effects.

Bring up the subject with all men over 50

To dispel these misconceptions and ensure that there are no current or ensuing serious complications,⁴ you should routinely talk about urinary function with every male patient over age 50. Because the incidence of BPH increases not only with age but also with other comorbid conditions such as diabetes⁷ and erectile dysfunction (ED),⁸ you should discuss the symptoms and potential complications of BPH with patients who present with these comorbidities. You can reassure them that BPH is not cancer, nor is it a precursor to prostate cancer; rather it is a fairly common, treatable disorder.

What's right for your patient? Watchful waiting? a-Blocker therapy? Surgery?

Questionnaire can help, addresses quality of life

Questionnaires such as the International Prostate Symptom Score (IPSS) (PATIENT HANDOUT)⁹ and the similar American Urological Association symptom index (AUA-SI) (available on page 44 of http://www.auanet.org/guidelines/main_reports/bph_management/chapt_1_appendix.pdf) can help you evaluate your patient's symptom severity.^2,6

The IPSS, with 3 categories of symptom severity (mild 0 to 7, moderate 8 to 19, severe 20 to 35) and a global quality-of-life question also referred to as the "Bother Score," is a validated tool for monitoring disease distress and clinical change.^10,11 The quality-of-life question is a good indicator for assessing whether watchful waiting might be preferred to active treatment.^9,12

FAST TRACK

Reassure patients that BPH is not cancer, nor is it a precursor to prostate cancer

Further categorizing the symptoms is not helpful. Lower urinary tract symptoms have traditionally been divided into irritative symptoms such as nocturia, urgency, and frequency, attributed to bladder and prostatic smooth muscle contractions, and obstructive symptoms such as hesitancy, decreased force of stream, and incomplete emptying, attributed to increased glandular mass.¹ This distinction, however, is not helpful inasmuch as irritative symptoms can result from increased tissue mass alone and obstructive symptoms from muscle hypertonicity alone; additionally, most BPH patients have a combination of both.^13,14

Consider comorbidities and overactive bladder

Common comorbidities for a patient with BPH include obesity, diabetes mellitus, and low high-density lipoprotein levels. Both irritative and obstructive symptoms are likely, without prior lower urinary tract disorders or ongoing neurological disease.^13-15 Multiple epidemiological studies have established clear, clinically relevant associations between BPH-related lower urinary tract symptoms and ED and ejaculatory dysfunction.⁸

It is also important to note that lower urinary tract symptoms may often arise due to overactive bladder; in fact, symptoms of overactive bladder and BPH overlap to a large degree.¹⁶ The diagnostic challenge is only increased by the fact that while overactive bladder is an additional cause of lower urinary tract symptoms, it may also coexist with BPH-related bladder outlet obstruction.¹⁷ The similarity in clinical presentation of the 2 conditions may make them hard to distinguish.