Benign prostatic hyperplasia. Practical treatment guidelines

Symptomatic benign prostatic hyperplasia (BPH) is a common condition in older men and has a significant impact on their daily lives. Transurethral resection of the prostate (TURP) or open prostatectomy are currently the most effective therapies for BPH. TURP is, however, associated with clinically significant adverse events in 20% of patients. Therefore, patients who need treatment for BPH based on the presence of symptoms should also be offered other therapy options. Transurethral incision of the prostate is an effective therapy with minimal adverse effects in patients with a prostate not larger than 30 g. Minimally invasive procedures, such as electrovaporisation, laser prostatectomy, transurethral needle ablation, high intensity focused ultrasound, transurethral microwave therapy and insertion of prostatic stents, can be performed instead of the standard surgical procedures. They are either performed as outpatient procedures or are associated with shorter durations of hospitalisation than TURP; in addition, they can also be performed in high risk patients. The efficacy of these procedures lies between that of TURP and medical therapy. Medical therapy is becoming increasingly important in the treatment of patients with moderate symptoms of BPH. Both androgen-suppressing therapy and alpha-adrenoceptor blockade are well tolerated and effective modalities. Compared with placebo, both types of therapy produce improvements in maximum urinary flat rate and reductions in symptom scores of 15 to 20%. Finasteride, a potent 5 alpha-reductase inhibitor, must be given for 6 months before it effectiveness in a given patient can be assessed, and for at least 12 months to achieve maximum prostate shrinkage and the full extent of its other beneficial effects. This may be perceived as a disadvantage when compared with the rapid relief afforded by surgery or alpha-blockade. The efficacy of finasteride is also dependent on prostate size; it should not be tried in patients with a prostate volume of < 40 ml. On the other hand, finasteride may reverse the progression of the disease process. Of the alpha 1-adrenoceptor antagonists, terazosin, doxazosin and tamsulosin can be administered once daily. In contrast, prazosin, alfuzosin and indoramin must be administered twice daily, which may have a negative impact on patient compliance. Because of its specificity for alpha 1A-receptors, no dosage titration is needed when tamsulosin is used; in addition, in contrast with the other alpha-blockers used in BPH, tamsulosin lacks significant effects on blood pressure. On the other hand, nonselective alpha-blockers are preferable in hypertensive patients with BPH. The final decision about the best treatment for a particular patient must take into account the patient's preference after he has been informed of the different options.