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.

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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.

South African star grass (Hypoxis rooperi and certain species of Pinus and Picea) contain beta-sitosterols and are sources for phytotherapeutic treatments for BPH. A systematic review analyzed the effects of beta-sitosterols in men and found improved urinary symptom scores and flow measures (n=519; 4 randomized, controlled, double-blind trials; duration, 4-26 weeks).²⁷ Their long-term effectiveness and safety are not known.

Cernilton, prepared from the ryegrass pollen Secale cereale, is marketed for the treatment of BPH. A Cochrane systematic review demonstrated that comparative trials lacked a proven active control. Available evidence suggests that short-term use of cernilton is well tolerated and modestly decreases overall urologic symptoms, including nocturia. Additional randomized placebo and active-controlled trials are needed to evaluate the long-term clinical effectiveness and safety of Cernilton.²⁸

Acupuncture was not effective in treating LUTS in men in randomized controlled (single-blinded) trials.²⁹

When patients don’t respond to medical treatment

Surgery is recommended for patients who have not responded to medical treatment, who have refractory retention with a failed attempt at catheter removal, or who experience recurrent UTIs, persistent hematuria, bladder stones, or renal insufficiency.³ In addition, surgery can be the initial treatment choice for patients with high AUA symptom scores who opt for this intervention and are good operative candidates.

FAST TRACK

Surgery can be the initial treatment of choice for patients with high AUA symptom scores who opt for this intervention and are good operative candidates.

The specific surgical approach (open or endoscopic; electrocautery or laser) are technical decisions based on the patient’s prostate size, the individual surgeon’s judgment, and the patient’s comorbidities.^1,30 For patients who are not surgical candidates, treatment with intermittent catheterization, an indwelling catheter, or a stent is recommended.

Acknowledgements

The authors thank Jen Creer, MA, of Edit Rx, LLC, for her assistance in the preparation of this manuscript. The University of Nebraska Medical Center, with which both authors were previously affiliated, funded this writing assistance.

Correspondence
Drew M. Keister, MD, Lehigh Valley Health Network, PO Box 7017, Allentown, PA 18105-7017; drew_m.keister@lvh.com