Benign prostatic hyperplasia: an insight into current investigational medical therapies

Benign prostatic hyperplasia (BPH) is a leading disorder of the elderly male population that is characterised by a progressive enlargement of prostatic tissue, resulting in obstruction of the proximal urethra and causing urinary flow disturbances. The pathophysiology of BPH associated with lower urinary tract symptoms is characterised by increased adrenergic tone (dynamic component) leading to smooth muscle contraction and prostatic overgrowth due to androgenic stimulation (static component); therefore, the therapeutic armamentarium of BPH can be broadly divided into antiadrenergic and antiandrogenic approaches. alpha1-Adrenoceptor antagonists and 5alpha-reductase inhibitors are well-established representatives of the two categories, respectively. Other antiandrogenic approaches involve gonadotropin-releasing hormone agonists and antagonists for the treatment of prostate hyperplasia. Apart from these approaches, new approaches with novel targets are emerging. The advent of new therapies is, however, more oriented towards the static component. These involve metabolic factors (hexokinase inhibitor), growth factors (vitamin D3 analogues), oxytocin antagonists and gonadotropin-releasing hormone Gi agonist-based therapies. Gene therapy and photodynamic therapies are other emerging therapies for relieving symptoms in BPH patients. With the initial success of upcoming targets, the unmet need to develop an efficacious and relatively safe therapeutic modality is discussed. Nevertheless, their long-term safety and efficacy needs to be evaluated in large-scale clinical trials. The future also belongs to combination therapies to combat both dynamic and static disease components and for extended indications such as micturition disorder and non-bacterial prostatitis.