Benign prostatic hyperplasia. Part 7: Treatment
Alternative surgical treatment
Many alternative procedures have been tried, including transurethral incision of prostate (TUIP), which is less likely to produce retrograde ejaculation and may have lower morbidity rates but higher re-operative rates (up to 20% at 10 years). Balloon dilatation is less invasive, but has significant recurrence rates. Laser ablation treatments (resection and vaporization) seem promising in reducing the length of stay in hospital, with an improvement in flow rate and symptoms intermediate between TURP and medical therapy. Thermotherapy is being evaluated. Urinary stenting is a quick procedure, carried out under local anaesthetic, with immediate, if temporary, relief There is a need for careful, controlled trials of these methods before they are widely adopted.
Medical treatment
There are three classes of medical treatment currently in use: alphablockers and 5-alpha reductase inhibitors, which have proven benefit, and phytotherapy, which is equivocal. All three medical treatments have been found to have substantial placebo effects in randomized controlled trials.
Alpha 1-adrenoreceptors are found both in the prostate smooth muscle and the base of the bladder. Blockade, with successful alleviation of symptoms, was first reported using phenoxybenzamine by Caine in 1984. Subsequent research has proved that selective alpha blockers prazosin, indoramin, alfuzosin, terazosin, and doxazosin are safe and effective but have numerous, mainly cardiovascular, side-effects. Doxazosin and terazosin, taken once daily, are more expensive, as is alfuzosin. Concerns that the effect of alpha blockers may not be sustained in the long term have been ameliorated by reports of efficacy (40-59% showing at least 30% improvement in QMax and safety of terazosin in a 42-month follow-up).
The 5-alpha reductase inhibitor, fmasteride, produces a reduction in prostate size (up to 28%) after 3-6 months, with an improvement in symptom score and increased uroflow found in at least 50% of men. Safety and efficacy on 3-year follow-up data showed good tolerance and sustained benefit; it is most effective in men with larger prostates. The side effects of finasteride are few (impotence 3.7%, decreased libido 3.3%, decreased ejaculation). With finasteride treatment, PSA values are halved at all levels and ages, and therefore, readings on treatment should be doubled to obtain the standard clinical measure.
Phytotherapy, pollen or plant extract is widely used by self-prescription. The limited trial work has yet to be replicated to establish efficacy, though cernilton has shown some benefit.
Prostatic cancer treatments including castration and hormonal treatments cause involution of the gland but are unacceptable for benign prostatic hyperplasia alone. Current research into growth factors and proto-oncogenes responsible for cell death, may hold longer-term promise for both benign prostatic hyperplasia and cancer.
Watchful waiting (WW)
Wasson reported on a comparison of WW versus TURP for moderate symptoms (AUA score 10-20), excluding men with hard indications for TURP. There were 27/249 treatment failures in the surgery group and 47/276 in the WW group (relative risk = 0.48; 95% CI = 0.3-0.77). The conclusion is that WW is a safe option. Barry has concluded that patient preferences should be the dominant factor in the US, where the use of interactive video in assisting decision making seems beneficial. There is at present insufficient evidence upon which to base guidelines as to the frequency of review as part of a watchful waiting management plan.
Conclusions
BPH is an underdiagnosed condition that significantly affects the quality of life of many men and should be part of opportunistic health promotion in men aged over 50. Diagnosis is not a simple matter of threshold symptom scores, nor reduced urinary flow, nor benign prostatic enlargement (BPE). The natural history remains unclear. A multifactorial approach to diagnosis is required with patients playing a large part in treatment choice. Where absolute indications for surgery are present, or severe bothersome symptoms, TURP remains the treatment of choice, but has significant morbidity and needs to have managed, long-term follow-up to prevent recurrence. New surgical treatments may prove valuable but need further evaluation. Medical treatments or watchful waiting in those men with moderate symptoms are acceptable options.
The coexistence of prostatic cancer is a problem in the continuing care of patients with benign prostatic hyperplasia, and complicates the shift from secondary to primary care of diagnosis and management. True-shared care is likely to develop as the hospital prostate assessment clinics become as overburdened as the urology clinics they have superceded. Management of benign prostatic hyperplasia will continue to require the skills of medicine as an art for some time, as much as an evidence-based approach.
Posted in: Benign Prostatic Hyperplasia