Medical Management of Benign Prostatic Hypertrophy in Older Men
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Introduction
Benign prostatic hypertrophy (BPH) is the most common cause of lower urinary tract symptoms (LUTS) in aging men and can occur in up to 70% of men over age 60.1 Symptoms can be progressive and often impact quality of life and even activities of daily living. Complications of BPH include obstructive nephropathy, recurrent urinary tract infections, and acute urinary retention. There are several management options for BPH currently available. This article reviews the evidence for the major medical treatment modalities for BPH available today. The aging population is heterogeneous, however, and management strategies for a community-dwelling older man may be different than those for older men living in long-term care (LTC) settings. Several treatment strategies, ranging from nonpharmacologic and surveillance to medical therapy to minimally invasive and surgical techniques, are appropriate based on severity of clinical symptoms. Quality-of-life issues must always be taken into consideration as well.
History
The exact cause for BPH is not well understood. It is known that the prostate enlarges as men age, that symptoms typically start by the fourth decade, and that by age 60 more than half of all men have some symptoms related to BPH. LUTS collectively includes common clinical manifestations of BPH such as increased frequency of urination, nocturia, hesitancy, urgency, and weak urinary stream. There is modest correlation among LUTS, peak urinary flow rates, and prostate volume, but the symptoms do not always match histologic findings. Specifically, benign prostatic hypertrophy refers to a histologically defined condition of stromal and epithelial hyperplasia of the prostate, particularly in the periurethral transitional zone.2 Histologic evidence of BPH does not always confer symptoms. Likewise, LUTS are not specific to BPH and may be due to other pathologies of the urinary system that warrant further investigation. If it is not known whether symptoms are due to BPH, a diagnostic workup for other causes such as urethral stricture, bladder neck contracture, prostate carcinoma, bladder stones, urinary tract infection, prostatitis, and neurogenic bladder should be performed. Medical comorbidities common in the geriatric male population (eg, type 2 diabetes, neurologic disease), as well as treatment with drugs that can impair bladder function (such as anticholinergics), can also cause LUTS and need to be further clarified.
Once it is established that the male patient has LUTS from BPH, there are four main treatment strategies: nonpharmacologic/surveillance, medical therapy, minimally invasive techniques, or invasive approach. Particular emphasis will be placed on medical therapy in this article.
Surveillance
In men who convey symptoms that are either not very bothersome or stable, nonpharmacologic interventions such as double voiding and scheduled voiding may be of help, and surveillance is often appropriate. Many older patients are already taking several medications and may be hesitant to add more medical therapy. Alternatively, men may mistakenly feel that such symptoms are a part of normal aging and may not offer complaints, thus the physician should inquire about LUTS. If symptoms are elicited, standardized validated scales such as the American Urological Association (AUA) symptom score, which addresses seven factors—frequency, hesitancy, nocturia, weak stream, intermittent stream, incomplete emptying, and urgency—can be used to assess severity; it must be noted that it is not intended to be used for differential diagnosis purposes.3 In general, in men who have mild symptoms (defined as AUA scale of 0-7), periodic monitoring and surveillance is appropriate. If symptoms worsen, treatment may be initiated based on a discussion of goals of care with the patient. If clinical issues such as infection or urinary retention are present, pharmacologic treatment is indicated.
1. Garraway WM, Russell EB, Lee RJ, et al. Impact of previously unrecognized benign prostatic hyperplasia on the daily activities of middle-aged and elderly men. Br J Gen Pract 1993;43:318-321.
2. Roehrborn C, McConnell JD. Etiology, pathophysiology, epidemiology, and natural history of benign prostatic hyperplasia. In:Walsh PC, Retik AB, Vaughan ED, et al, eds. Campbell’s Urology. 8th ed. Philadelphia, PA: WB Saunders; 2002:1297-1336.
3. Barry MJ, Fowler FJ Jr, O’Leary MP, et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol 1992;148:1549-1557, 1564.
4. Caine M, Perlberg S, Meretyk S. A placebo-controlled double-blind study of the effect of phenoxybenzamine in benign prostatic obstruction. Br J Urol 1978;50:551-554.
5. Caine M. The present role of alpha-adrenergic blockers in the treatment of benign prostatic hypertrophy. J Urol 1986;136:1-4.
6. Djavan B, Chapple C, Milani S, Marberger M. State of the art on the efficacy and tolerability of alpha 1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Urology 2004;64:1081-1088.
7. Lepor H, Lowe FC. Evaluation and nonsurgical management of benign prostatic hyperplasia. In: Walsh PC, Retik AB, Vaughan ED, et al, eds. Campbell’s Urology. 8th ed. Philadelphia, PA: WB Saunders; 2002:1337-1378.
8. Djavan B, Marberger M. A meta-analysis on the efficacy and tolerability of alpha 1-adrenoreceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction. Eur Urol 1999;36:1-13.
9. Wilt TJ, Howe RW, Rutks IR, MacDonald R. Terazosin for benign prostatic hyperplasia. Cochrane Database Syst Rev 2002;(4):CD003851.
10. McConnell JD, Roehrborn CG, Bautista OM, et al; Medical Therapy Of Prostatic Symptoms (MTOPS) Research Group. 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.
11. Emberton M, Zinner N, Michel MC, et al. Managing the progression of lower urinary tract symptoms/benign prostatic hyperplasia: therapeutic options for the man at risk. BJU Int 2007;100:249-253.
12. AUA Practice Guidelines Committee. AUA guideline on management of benign prostatic hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations. J Urol 2003;170(2 Pt 1):530-547.
13. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: The Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT). ALLHAT Collaborative Research Group [published correction appears in JAMA 2002;288(23):2976]. JAMA 2000;28315):1967-1975.
14. Thomas DR. Pharmacologic management of urinary incontinence. Clin Geriatr Med 2004;20:511-523, vii-viii.
15. Boyle P, Gould AL, Roehrborn CG. Prostate volume predicts outcome of treatment of benign prostatic hyperplasia with finasteride: Meta-analysis of randomized clinical trials. Urology 1996;48:398-405.
16. Carson C 3rd, Rittmaster R. The role of dihydrotestosterone in benign prostatic hyperplasia. Urology 2003;61:2-7.
17. Lackner TE. Pharmacotherpay of urinary incontinence. J Am Med Dir Assoc 2002;3(1 suppl):S16-S24.
18. 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. N Engl J Med 1996;335:533-539.
19. Kirby RS, Roehrborn C, Boyle P, et al; Prospective European Doxazosin and Combination Therapy Study Investigators. Efficacy and tolerability of doxazosin and finasteride, alone or in combination, in treatment of symptomatic benign prostatic hyperplasia: The Prospective European Doxazosin and Combination Therapy (PREDICT) trial. Urology 2003;61:119-126.
20. Kaplan SA, Roehrborn CG, Rovner ES, et al. Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder: A randomized controlled trial [published corrections appear in JAMA 2007;297(11):1195 and JAMA 2007;298(16):1864]. JAMA 2006:296(19):2319-2328.
21. Bouza C, López T, Magro A et al. Systematic review and meta-analysis of Transurethral Needle Ablation in symptomatic benign prostatic hyperplasia. BMC Urol 2006;6:14.
22. Hoffman RM, MacDonald R, Monga M, Wilt TJ. Transurethral microwave thermotherapy vs transurethral resection for treating benign prostatic hyperplasia: A systematic review. BJU Int 2004;94:1031-1036.
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