Despite the deceptively simple description of benign prostatic hyperplasia BPHthe actual relationship between Cane BPH 11, lower urinary tract symptoms LUTSbenign prostatic enlargement, and cane BPH 11 outlet obstruction is complex and requires a solid understanding of the definitional issues involved. There are many medical and minimally invasive treatment options available for affected patients. Cane BPH 11 the intermediate and long term, minimally invasive treatment options are superior to medical therapy in terms of symptom and flow rate improvement; tissue ablative surgical treatment options are superior to both minimally invasive and medical therapy.
Benign prostatic hyperplasia BPH refers to the nonmalignant growth of the prostate observed very commonly in aging men. Although on the surface this statement seems straightforward and simple, there are considerable definitional problems associated with the condition that subsequently lead to problems with epidemiologic definitions, calculations of incidence and prevalence rates, and, ultimately, difficulties with formalizing therapeutic algorithms.
BPH, the actual hyperplasia of the prostate gland, develops as a strictly age-related phenomenon in nearly all men, starting at approximately 40 years of age. No doubt, when living long enough, most men will develop some histologic features consistent with BPH.
In fact, many men with histologic BPH will never see a doctor for cane BPH 11 condition, nor do they ever need any treatment cane BPH 11 it.
The condition becomes a clinical entity if and when it is associated with subjective symptoms, the most common manifestation being lower urinary tract symptoms LUTS. The LUTS symptom complex can be conveniently divided into obstructive and irritative symptoms. Among the obstructive symptoms are hesitancy, straining, weak flow, prolonged voiding, partial cane BPH 11 complete urinary retention, and, ultimately, overflow incontinence.
The often more bothersome irritative symptoms consist of frequency, urgency with urge cane BPH 11, nocturia, and painful urination, as well as small voided volumes.
The prevalence of LUTS increases steadily with increasing age. Observations to this effect have been obtained from many cross-sectional studies in various countries and racial groups. Considerable efforts have been expended to understand the reasons men do or do not consult a health care provider when experiencing LUTS. In many cases, these symptoms are accepted as a natural occurrence with aging, and cane BPH 11 learn to live with them.
Also, the threshold for men to seek consultation with a health care provider cane BPH 11 LUTS differs greatly within and between racial groups. Ultimately, however, when men are significantly bothered by these symptoms, they will usually consult a health care provider in hopes of remedying the cane BPH 11. This phenomenon has been investigated cane BPH 11 longitudinal and cross-sectional studies in various ethnic groups, starting with the original autopsy study conducted cane BPH 11 Berry cane BPH 11 colleagues.
These studies demonstrate that across a wide spectrum of racial and ethnic groups, prostate size increases from 25 g to cane BPH 11 g for men in their 40s to 30 g to 40 g for men in their 50s and to 35 g to 45 g for men in their 60s. At the same time, the transition zone of the prostate, which is quite small at approximately 15 g in men in their 40s, increases to approximately 25 g for men in their 60s and 70s.
Many men with significant LUTS and bother have a normalsized prostate, whereas many men with large prostates present with surprisingly few, if any, symptoms. The last part of the complex relationship is the issue of bladder outlet obstruction BOO Figure 1. For example, a primary bladder neck sclerosis, a urethral stricture, or cane BPH 11 conditions might cause significant obstruction while not being associated with histologic BPH.
BOO can be cane BPH 11 by invasive pressure-flow studies or noninvasively tested for by urinary flow rate recordings. This condition, cane BPH 11 it is the most commonly cited and the one associated with a recognizable ICD-9 code, might or might not be associated with the presence of bothersome LUTS, anatomic enlargement of the prostate BPEand a compression of the urethra with compromised urinary flow and BOO.
Despite many decades of intense research, the etiology of BPH is still poorly understood. Of the dominant hypotheses, the hormonal or dihydrotestosterone DHT hypothesis is most often invoked.
It is clear cane BPH 11 male gender with functioning testes present at the time of puberty and aging are paramount to the development of BPH. Additional risk factors include a positive family history, because early BPH may occur as a familial disease.
Despite intense epidemiologic research, smoking, cane BPH 11, and sexual cane BPH 11 or the lack thereof have not been conclusively linked to the development of BPH. Increased physical activity and alcohol taken in moderation seem to protect from BPH.
As mentioned earlier, BPH in itself might not cause any problem and thus might not call for immediate treatment. Patients most often seek consultation with a health care provider for cane BPH 11 LUTS.
Much research has demonstrated that cane BPH 11 LUTS can interfere with activities of daily living, cause significant impairment of the disease-specific quality of cane BPH 11, and interfere with sexual functioning. A large, multinational, survey-based study demonstrated that, independent of age, men with more severe LUTS also more often experienced sexual dysfunction.
The exact pathophysiology for this relationship has not been fully understood, and it is still unclear whether this is a causal or coincidental relationship, but it is noteworthy that men with sexual dysfunction often have LUTS, and vice versa. BPE and BOO have been linked to outcomes other than symptom severity that are of significance and thus are worthy of the attention of health care providers. For example, the cane BPH 11 rates of acute urinary retention episodes and subsequent surgical interventions are higher in men with larger prostate glands compared with those with smaller cane BPH 11.
Also, subvesical obstruction or BOO might be responsible for secondary changes of the bladder anatomy and function, urinary tract infections, formation of bladder stones, and ultimately deterioration of the upper urinary tract with renal failure. The high prevalence of histologic BPH, bothersome LUTS, BPE, and BOO has been emphasized, and the number of cane BPH 11 presenting with these symptoms to health care providers engaged in the care of such patients will likely increase significantly over the next decades.
In addition, life expectancy has changed worldwide from 56 years cane BPH 11 the observation period to to 65 years for to Again, the more developed cane BPH 11 have a longer life expectancy, but the incremental increase is greater in Africa, Asia, and Latin America and the Caribbean regions Figure 2B.
Trends cane BPH 11 aging and life expectancy. A Percentage of population aged 65 years and older, by world region. B Trends in life expectancy at birth in yearsby cane BPH 11 region. Data from United Nations.
DRE is notoriously unreliable in assessing the size of the prostate. In fact, DRE has been shown to underestimate the size of the prostate, with the degree of underestimation increasing with the actual size of the prostate.
In addition, urinalysis and a cane BPH 11 prostate-specific antigen PSA assay is recommended as part of the additional diagnosis. Guidelines for the evaluation of men with lower urinary tract symptoms and benign prostatic hyperplasia.
Upon initial presentation, certain patients might be immediately referred to minimally invasive or surgical treatment. In the past, men presenting with refractory urinary retention were believed cane BPH 11 require immediate surgical cane BPH 11. Even patients with bladder stones do not necessarily need to be referred for surgery. The vast majority of patients are further evaluated by quantitative symptom score assessment.
There is a large variety of self-administration questionnaires that may be given to patients to assess symptom frequency and severity, interference with daily activity, quality of life, issues of urinary continence or incontinence, cane BPH 11 functioning, and other health-related general or disease-specific quality-of-life issues. The questionnaire is self-administered and elicits a response score ranging from 0 to 35 points.
Men scoring from 0 to 7 points are classified as not or mildly symptomatic, those scoring between 8 and 18 points as moderately symptomatic, and those scoring 19 points or greater as severely symptomatic. The most commonly used measure of sexual function is the International Cane BPH 11 of Erectile Function, a multidimensional scale for the assessment of erectile dysfunction.
It is generally recommended that those patients scoring less than 8 points and who exhibit no or insignificant bother due to these symptoms be classified as not or mildly symptomatic, and the recommendation most often made is for watchful waiting or yearly reevaluation.
Those patients who score in the moderate or severe range on the IPSS and report bother from these symptoms might undergo additional or optional testing before a discussion of treatment options. Although such tests are not always necessary, specifically before the initiation of medical therapy, they might be helpful in patients with a complex medical history, neurological diseases known to affect bladder function, prior failed BPH therapy, and certainly in those patients desiring minimally invasive or surgical therapy.
Urinary flow rate recording is a noninvasive way to determine the intensity or strength of the urinary stream. Measurement of postvoid residual urine can be performed by transabdominal ultrasonography or in-and-out catheterization, the former being the preferred method.
Postvoid residual urine values differ substantially over time cane BPH 11 an individual and between individuals. However, it is widely accepted that rising amounts of residual urine and decreasing voiding efficiency are associated with worsening of the condition and a greater likelihood of acute urinary retention with subsequent need for surgery.
Invasive pressure-flow studies or formal urodynamic studies are the best tests to determine whether a patient is obstructed at the level of the bladder neck. Appropriate nomograms have been established for normative values regarding the pressure-flow parameters, and it is commonly accepted that the best marker of obstruction is the pressure within the bladder generated by the detrusor muscle at the time of the maximum urinary flow rate.
In fact, transrectal ultrasound of the prostate is the most common imaging modality for the assessment of prostate size and shape. Inasmuch as prostate size is predictive of the natural history of the disease and the subsequent cane BPH 11 of surgery but also important in determining the appropriateness of certain therapeutic interventions, it is a recommended test in those patients seeking certain minimally invasive transurethral microwave thermotherapy [TUMT], transurethral needle ablation [TUNA] or surgical therapeutic options, while it is not needed or cane BPH 11 prior to other minimally invasive interventions such as interstitial laser coagulation ILC of the prostate.
Imaging of the upper urinary tract by intravenous urography or computerized tomography is rarely indicated because patients with Cane BPH 11 and BPH do not have an increased incidence of significant lesions eg, renal tumors or stones of the upper urinary tract cane BPH 11 with age-matched controls. Endoscopic examination of the lower urinary tract by cystourethroscopy is also rarely indicated before embarking on surgical treatment. However, the anatomy of the prostate, the appearance of the bladder neck, the presence or absence of an intravesical lobe, and the condition of the bladder muscle and mucosa might alter the surgical approach eg, transurethral resection vs incision of the cane BPH 11 and assessment of these factors is indicated before embarking on minimally invasive interventions such as ILC or other cane BPH 11 procedures.
Depending on the individual circumstances and presentation, as well as the familiarity and comfort the health care provider has with the various interventions, a multitude of medical or surgical interventions might be contemplated.
For those men presenting with mild symptoms and those with moderate symptoms but limited bother due to their symptoms, watchful waiting ie, a strategy of yearly reevaluation and reassurance are certainly appropriate.
This strategy is based on the observation that progression of symptoms in these patients is rare and development of serious complications is uncommon. The use of phytotherapeutics has increased significantly over the last decade in the United States, whereas it has always been very popular in Europe.
Among the more popular natural compounds are the fruit of the American dwarf palm tree saw palmetto or Serenoa repensan extract made from cane BPH 11 bark of the African plum tree Pygeum africanumpumpkin seeds, rye pollen extracts, South African star grass roots, the root of the stinging nettle, or the purple cone flower.
Many smaller and short-term studies have demonstrated improvement in symptoms with such compounds, but there is a paucity of well-conducted, long-term, or placebo-controlled studies for any of these products, and many of the results are conflicting. There are excellent reviews available regarding this topic. In addition, there is a significant lot-to-lot variability in the actual ingredients, and quality control of these products is, comparatively speaking, poor. Nonetheless, if patients feel that they are subjectively improved, it will prove difficult for the health care provider to discourage the use of these over-the-counter agents.
Here, a clear pathophysiologic rationale is present. An increase in the tone leads to a reduction in the urinary flow rate ie, obstruction and worsening of LUTS. Accordingly, a blockage of the receptor leads to improvement of the urinary flow rates and LUTS.
Although there are subtle differences between these drugs in terms of their side-effect profiles, they cane BPH 11 fundamentally all equally effective in alleviating bothersome LUTS and improving urinary flow rates Figure 4. Both terazosin available as 1, 2, 5, and cane BPH 11 mg and doxazosin available as 1, 2, 4, and 8 mg require titration owing to the first dose effect to reach the maximum recommended doses of 10 and 8 mg, respectively.
Tamsulosin is available in 0. Alfuzosin is available only as a single, mg slow-release formulation, and no dose titration is recommended. Reproduced with permission from Djavan et al. In contrast to the relatively equal efficacy of all 4 drugs currently available, there are some differences regarding the adverse event spectrum. Terazosin and doxazosin induce more dizziness, fatigue, and asthenia, whereas tamsulosin induces more ejaculatory disturbances.
However, actual discontinuation due to any of these side effects is not common, and discontinuation rates are relatively cane BPH 11 among these compounds. Thus, these drugs are not able to alter the natural history of the disease significantly. In contrast, the second class of compounds has remarkable abilities in terms of altering the natural history of the disease. DHT enters the epithelial cell, binds to the androgen receptor, and then induces alterations of the deoxyribonucleic acid, leading ultimately to such metabolic effects as protein synthesis and secretion and growth of the prostate.
Finasteride was introduced in the s for the treatment of BPH. Finasteride has a serum half-life of 6 to 8 cane BPH 11, whereas cane BPH 11 of dutasteride cane BPH 11 5 weeks. Improvement in IPSS is similar for finasteride and dutasteride and significantly superior to that with placebo.