What’s best for your patient with BPH?

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Applied Evidence

What’s best for your patient with BPH?

J Fam Pract. 2009 May;58(5):241-247

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References

1. American Urological Association. AUA guideline on the management of benign prostatic hyperplasia: diagnosis and treatment recommendations. 2003/updated 2006. Available at: http://www.auanet.org/content/guidelines-and-quality-care/clinicalguidelines.cfm?sub=bph. Accessed April 2, 2009.

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

3. McConnell JD. Clinical practice guideline no. 8: Benign prostatic hyperplasia: diagnosis and treatment. Benign Prostatic Hyperplasia Guideline Panel. Rockville, Md: US Dept of Health and Human Services, Agency for Health Care Policy and Research; 1994. AHCPR publication 94-0582.

4. Austin O, Ricer RE. (1996). Prostate cancer screening: an appraisal of the PSA test. Fam Pract Recert. 1996;18:81-91.

5. 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. J Urol. 1992;148:1549-1557.

6. Denis LJ. Diagnosing benign prostatic hyperplasia versus prostate cancer. Br J Urol. 1995;76(suppl 1):S17-S23.

7. Andriole GL, Crawford ED, Grubb RL, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009;360:1310-1319.

8. Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360:1320-1328.

9. American Cancer Society Guidelines for the Early Detection of Cancer. Revised March 5, 2008. Available at: http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp. Accessed April 6, 2009.

10. US Preventive Services Task Force. Screening for prostate cancer: recommendation statement. Available at http://www.ahrq.gov/clinic/uspstf08/prostate/prostaters.htm. Accessed April 3, 2009.

11. American Cancer Society. Cancer Facts & Figures. Atlanta, Ga: 2008. Available at http://www.cancer.org/downloads/STT/2008CAFFfinalsecured.pdf. Accessed on April 3, 2009.

12. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society guidelines for the early detection of cancer. CA Cancer J Clin. 2006;56:11-25.

13. Ilic D, O’Connor D, Green S, et al. Screening for prostate cancer. Cochrane Database Syst Rev. 2006;(3):CD004720.-

14. Barry MJ. Evaluation of symptoms and quality of life in men with benign prostatic hyperplasia. Urology. 2001;58(suppl 1):S25-S32.

15. Polascik TJ, Oesterling JE, Partin AW. Prostate specific antigen: a decade of discovery—what we have learned and where we are going. J Urol. 1999;162:293-306.

16. Wilt T, Howe RW, Rutks I, et al. Terazosin for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2002;(4):CD003851.-

17. 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. N Engl J Med. 2003;349:2387-2398.

18. Wilt T, MacDonald R, Rutks I. Tamsulosin for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2003;(1):CD002081.-

19. Guess HA, Gormley GJ, Stoner E, et al. The effect of finasteride on prostate specific antigen: review of available data. J Urol. 1996;155:3-9.

20. 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.

21. Garraway WM, Collins GN, Lee RJ. High prevalence of benign prostatic hypertrophy in the community. Lancet. 1991;338:469-471.

22. Lepor HL, Williford WO, Barry MJ, et al. The efficacy of terazosin, finasteride, or both in benign prostatic hyperplasia. N Engl J Med. 1996;335:533-540.

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

24. Wilt T, Ishani A, MacDonald R. Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev. 1999;(1):CD001423.-

25. 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. Am J Med. 2000;109:654-664.

26. Wilt T, Ishani A, MacDonald R, et al. Pygeum africanum for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2002;(1):CD001044.-

27. Wilt T, Ishani A, MacDonald R, et al. Beta-sitosterols for benign prostatic hyperplasia. Cochrane Database Syst Rev. 1999;(4):CD001043.-

28. Wilt T, MacDonald R, Ishani A, et al. Cernilton for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2000;(2):CD001042.-

29. Johnstone PA, Bloom TL, Niemtzow RC, et al. A prospective, randomized pilot trial of acupuncture of the kidney-bladder distinct meridian for lower urinary tract symptoms. J Urol. 2003;169:1037-1039.

30. Keister DM, Neal R. Managing BPH: when to consider surgery. Am Fam Physician. 2008;77:1391-1392.

31. Finnish Medical Society Duodecim. Benign prostatic hyperplasia. In: EBM Guidelines. Evidence-Based Medicine [CD-ROM]. Helsinki, Finland: Duodecim Medical Publications Ltd; 2005.

Talk to your patient about the controversial PSA test. Measuring serum prostate-specific antigen (PSA) levels to screen for prostate cancer is controversial, even for patients with LUTS. Although PSA testing can effectively detect prostate cancer in its early pathologic stages, researchers continue to investigate whether early detection significantly improves outcomes. Quite recently, 2 studies demonstrated that the test saves few lives;^7,8 1410 men would need to be screened and 48 additional cases of prostate cancer would need to be treated to prevent 1 death from prostate cancer.

A subset of detected cancers appears to be clinically significant, but many cancers will not progress during a patient’s lifetime.^3,5 The United States Preventive Services Task Force (USPSTF) has concluded that the evidence is insufficient to recommend for or against routine prostate cancer screening due to the uncertainty of the balance of potential benefits (reduction of prostate cancer morbidity and mortality) and risks (false-positive results, unnecessary biopsies, and possible complications) of treatment for early disease.^9-12 Furthermore, in its 2008 update, the USPSTF specifically recommended against screening for prostate cancer in men 75 years of age and older.

The American Cancer Society says that discouraging or not offering testing is inappropriate: Men who ask their physicians to make the decision on their behalf should be tested.⁹ A 2006 Cochrane review of this topic found only 2 eligible randomized trials, both of which had high risk of bias. They concluded that insufficient high-quality evidence exists to support or refute the use of any screening for prostate cancer in any patient population, including those with BPH.¹³

Given this conflicting advice, discuss the benefits and limitations of screening with your patient before deciding whether or not to test.

What is the optimal Approach to treatment?

Patients who are not bothered by their urinary symptoms—even those with moderate to severe symptom scores—can be managed with watchful waiting. Because of the cost and frequent side effects of medications for BPH, these patients generally will not benefit from drug therapy.^3,5,14,15 However, follow-up monitoring is important, because the severity of BPH can change even without treatment.

FAST TRACK

Patients not bothered by urinary symptoms—even those with moderate to severe symptom scores—can be managed with watchful waiting.

Even if patients with moderate or severe AUA symptom scores are not bothered by their symptoms, inform them of appropriate treatment options.³ When urinary obstruction symptoms from BPH significantly interfere with daily living and sleep activities, treatment is justified.¹

Medical management, yes, but which option?

Medical therapies are not as effective as surgical intervention,¹⁶ but they often provide adequate symptom relief and cause fewer, less severe, and less permanent adverse effects than surgery. Initiate treatment with medical therapy if (1) the patient is bothered by his symptoms, (2) no significant urinary obstruction exists, and (3) you have followed the patient’s preference for prostate cancer evaluation. TABLE 2 lists prescription medications for the treatment of BPH.

Nonselective α-adrenergic blockers, such as doxazosin and terazosin, reduce prostatic smooth muscle tone, thereby improving urinary flow. A Cochrane systematic review and a subsequent large randomized trial found terazosin to be superior to placebo in improving urinary flow and decreasing symptoms in men with BPH.^16,17

FAST TRACK

If you conduct PSA screening for prostate cancer in a patient taking finasteride, double the PSA level before comparing it with age-related norms.

Selective α-adrenergic blockers, such as alfuzosin and tamsulosin, are highly selective α-1_A-adrenergic antagonists. They are believed to be as effective as the nonselective agents, and patients may experience fewer side effects than with nonselective agents.^1,18 However, these drugs are considerably more expensive than their nonselective counterparts.

5-α Reductase inhibitors, such as finasteride and dutasteride, are more effective than placebo for patients with LUTS associated with demonstrable prostate enlargement. In a Cochrane review and subsequent large randomized trial, finasteride proved inferior to terazosin.^16,17 However, finasteride reduces the progression to urinary obstruction and the need for invasive therapy; terazosin does not.¹⁷ Finasteride achieves this effect by reducing prostatic volume by about 20% over 3 to 6 months of treatment.

Finasteride decreases PSA levels by 40% to 50%. If you conduct PSA screening for prostate cancer in a patient taking finasteride, double the PSA level before comparing it with age-related norms. Handled this way, PSA screening will not lose its sensitivity or specificity for the diagnosis of prostate cancer.¹⁹

Though a 5-mg daily regimen of finasteride reduces the overall risk of prostate cancer from 24.4% to 18.4%, it increases the risk of high-grade disease associated with higher mortality from 5.1% to 6.4%. Warn patients of this risk.²⁰