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PEER REVIEW: UROLOGY
Current Treatment Options for Benign Prostatic Hyperplasia Written by Charles O’Connor, Patrick Collins and Gregory Nason BPH are alpha-adrenergic blockers including tamsulosin, alfuzosin and doxazosin and 5-alpha reductase inhibitors (5-ARIs) including dutasteride and finasteride, combination therapy is also common in the form of tamsulosin/ dutasteride or “Combodart”.
Charles O'Connor
Patrick Collins
Gregory Nason
Introduction
Risk factors for BPH
Benign prostatic hyperplasia (BPH) is a histologic diagnosis of prostatic enlargement from benign proliferation of epithelial prostate cells as well as smooth muscle. BPH prevalence increases with age with rates ranging from 50% to 75% for men older than 50 years of age to 80% in men 70 years of age and older.1 The average prostate volume is 20-30cc, patients with BPH will typically have a larger prostate volume than 30cc. BPH is often diagnosed with patients experiencing lower urinary tract symptoms (LUTS). These can be broadly categorised in to storage and voiding LUTS. Storage LUTS include frequency, urgency, nocturia and occasional incontinence. Voiding LUTS include hesitancy to start flow, straining, intermittent ‘or stopstart’ flow and a sensation of incomplete emptying. An objective measure of LUTS severity is the use of the international prostate symptoms score (IPSS). This score is the same as the validated American urological associate symptom index (AUASI) score but it asks one more key question- “If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about this?”. The IPSS is shown in figure 1.2
Risk factors that are associated with BPH include age, lack of exercise, smoking, excessive alcohol consumption, obesity, hypertension, diabetes, hyperlipidaemia and a genetic disposition. Factors that tend to decrease the risk of BPH include increased physical activity, moderate or decreased alcohol intake and increased vegetable consumption.3 Thus, like with many conditions, the first steps to manage BPH should be in terms of lifestyle modification. Other methods of lifestyle modification to deal with LUTS secondary to BPH include cutting out factors that cause increased frequency or nocturia. This can include cutting out or limiting caffeine or medications that increase frequency e.g., diuretics. For patients who experience nocturia a practical first step to manage this is to limit fluid intake in the hours prior to sleeping. Medical management of BPH
antigen (PSA) test to screen for prostate cancer. Guidelines suggest that PSA should only be checked in a patient with a life expectancy of 10 years or more and after discussion of the risks and benefits of screening. A digital rectal examination (DRE) should be carried to assess the prostate size and the presence of masses or nodules, although this examination tends to under-estimate prostate volume.4 Urinalysis can be performed to out rule the presence of a urinary tract infection (UTI). The use of the IPSS score can assess severity of symptoms. If bladder outflow obstruction (BOO) is suspected, laboratory tests including creatinine should be checked and an ultrasound performed of a patient’s bladder post-void to ensure sufficient emptying- generally termed PVR (post void residual). A uroflowmetry test can also be carried out which measures a patient’s maximum flow rate (Qmax), average flow rate and voided volume. The pattern of flow can give an insight into the aetiology of the symptoms.
Medical management of LUTS generally starts with a patient’s primary care physician. As a recent increase in LUTS can be associated with prostate cancer, consideration can be given to performing a prostate specific
Medical management for BPH can be initiated if a patients LUTS fall in to the moderate or severe class as per their IPSS score or if their mild LUTS are bothersome to them. The two main classes of medication for
AUGUST 2022 • HPN | HOSPITALPROFESSIONALNEWS.IE
Alpha blockers work by blocking sympathetic nerve fibres which decreases contraction of smooth muscle at the bladder neck and improves emptying. Symptomatic relief is generally noted after 1 week of use but may take up to 4 weeks. IPSS scores improve by 5-8 points by taking an alpha blocker. As alpha blockers were initially developed as antihypertensive agents, one of their main side effects is orthostatic hypotension. Other side effects of alpha blockers include headache, retrograde ejaculation and with tamsulosin especially a condition called ‘floppy iris syndrome’ after ophthalmic surgeons noted iris flopping or prolapsing during cataract surgery. Men should not be started on an alpha blocker if planning this surgery. Notably, in contrast to tamsulosin, alfuzosin does not cause retrograde ejaculation and one recent systematic review confirmed that it may even improve ejaculatory function.5 Antimuscarinic medications work by blocking muscarinic receptors from the action of acetylcholine which mediates parasympathetic nerves. Alpha blockers can be combined with antimuscarinic mediations like solifenacin in men with BPH who have predominantly bladder storage systems. The EAU strongly recommends their use in this subset of patients and the risk of acute urinary retention is rare with these provided a patients’ PVR is less than 150mls.6 Beta-3 agonists like Betmiga similarly improve these storage symptoms and can be used in combination with alpha-blockers. Both testosterone and DHT are implicated in the stimulation of prostatic tissue. The second
