Benign prostatic hyperplasia

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Benign prostatic hyperplasia, or BPH, is very common in older men. The prostate is enlarged, but it is not cancerous. Over time, an enlarged prostate may press against the urethra, making it hard to urinate.

Diagnosis

BPH may cause dribbling after urinating or a need to urinate often, especially at night. A doctor will do a rectal exam to check for BPH. And he may suggest having special x-rays or scans to check the urethra, prostate, and bladder.

The physical examination has limited ability to measure the prostate volume:[1][2][3] The normal prostate is about the size of a walnut or less than 30 ml.

  • Estimating a volume of more than 30 ml on rectal examination has a sensitivity of less than 50% in detecting a gland of more than 30 ml.[2]
  • Estimated a posterior surface area of more than 7 cm2 has a sensitivity of 70% for detecting a volume of more than 30 ml.[3] Of note, an area of 7 cm2 indicates a circle with diameter of 3 cm or a square with diameter of approximately 2.5 cm2.

The American Urological Association Urinary symptom score is a validated measure of severity of symptoms.[4]

The prostate specific antigen (PSA) level in the blood may predict size.[5]


American Urological Association Urinary symptom score: ASK THE FOLLOWING QUESTIONS: Over the past month:

  1. How often have you had a sensation of not emptying your bladder after you finish urinating?
  2. How often have you had to urinate again after you finish urinating?
  3. How often have you found you stopped and started again several times when you urinated?
  4. How often have you found it difficult to postpone urination?
  5. How often have you had a weak urinary stream?
  6. How often had you had to push or strain to begin urination?
  7. How many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?
ANSWER THE QUESTIONS AS FOLLOWS, POINTS ARE BELOW:
Not at    < 1      < than 1/2     About 1/2      > than 1/2      Almost
all    time in 5     the time     the time        the time       always
0          1            2             3               4             5

Total Score:
0-7     mild
8-19    moderate
20-35   severe

Ultrasonography

Estimation of post-void residual volume by ultrasonography may not always show elevated values.[6][7][8]

Treatment

If the symptoms are not too bad, the doctor may suggest "watchful waiting" before starting any treatment. This includes regular checkups. Treatment can start later on if symptoms get worse.

Medications

Combination therapy

Finasteride combined with doxazosin is better than either drug alone according to a meta-analysis by the Cochrane Collaboration. [14] Alfuzosin and finasteride are generic.

Randomized controlled trials of combination therapy for benign prostatic hypertrophy.[15][16][17]
Trial Patients Intervention Control Outcome Results
(% AUA score increase by ≥ 4 points)
Combination Alpha adrenergic blocker only 5-alpha-reductase inhibitor only
CombAT[15]
2009
Uncontrolled factorial trial
Industry sponsored
Mean prostate volume was 54 ml tamsulosin 0.4 mg and/or dutasteride 0.5 daily Placebo Composite at 4 years 8.6% 14.2% 13.1%
Medical Therapy of Prostatic Symptoms (MTOPS) Research Group[16]
2003
Factorial trial
Government sponsored
Mean prostate volume was 36 ml doxazosin 8 mg and finasteride 5 mg daily Placebo Composite at 4.5 years 5% 7% 9%
Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group[17]
1996
Factorial trial
Government sponsored
  terazosin 10 mg and finasteride 5 mg daily Placebo Various at one year    

Alpha adrenergic blockers have been combined with testosterone 5-alpha-reductase inhibitors in randomized controlled trials.[16][17]

Surgery

An operation can improve the flow of urine but it can also cause other problems. Usually, men have surgery only if medicine hasn’t worked. This surgery does not protect against prostate cancer. Regular check-ups are important after BPH surgery. There are three kinds of surgery:

  • Transurethral resection of the prostate (TURP) is the most common type of surgery. The surgeon takes out part of the prostate through the urethra.
  • Transurethral incision of the prostate (TUIP) may be used when the prostate is not too large. The doctor makes a few small cuts in the prostate near the opening of the bladder.
  • Open surgery is used only when the prostate is very large. The doctor removes the prostate through a cut in the belly or behind the scrotum.

References

  1. Roehrborn CG, Girman CJ, Rhodes T, Hanson KA, Collins GN, Sech SM et al. (1997). "Correlation between prostate size estimated by digital rectal examination and measured by transrectal ultrasound.". Urology 49 (4): 548-57. PMID 9111624[e]
  2. 2.0 2.1 Bosch JL, Bohnen AM, Groeneveld FP (2004). "Validity of digital rectal examination and serum prostate specific antigen in the estimation of prostate volume in community-based men aged 50 to 78 years: the Krimpen Study.". Eur Urol 46 (6): 753-9. DOI:10.1016/j.eururo.2004.07.019. PMID 15548443. Research Blogging.
  3. 3.0 3.1 Roehrborn CG (1998). "Accurate determination of prostate size via digital rectal examination and transrectal ultrasound.". Urology 51 (4A Suppl): 19-22. PMID 9586592[e]
  4. Barry MJ, Fowler FJ, O'Leary MP, et al (November 1992). "The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association". J. Urol. 148 (5): 1549–57; discussion 1564. PMID 1279218[e]
  5. Jacobson DJ, St Sauver JL, Parker AS, McGree ME, Sarma AV, Girman CJ et al. (2011). "Estimation of prostate size in community-dwelling men.". Urology 77 (2): 422-6. DOI:10.1016/j.urology.2010.05.044. PMID 20800880. PMC PMC3010416. Research Blogging.
  6. Wasson JH, Reda DJ, Bruskewitz RC, Elinson J, Keller AM, Henderson WG (1995). "A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate.". N Engl J Med 332 (2): 75-9. DOI:10.1056/NEJM199501123320202. PMID 7527493. Research Blogging.
  7. McNeill SA, Hargreave TB, Geffriaud-Ricouard C, Santoni J, Roehrborn CG (2001). "Postvoid residual urine in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia: pooled analysis of eleven controlled studies with alfuzosin.". Urology 57 (3): 459-65. PMID 11248620[e]
  8. Nwosu CR, Khan KS, Chien PF, Honest MR (1998). "Is real-time ultrasonic bladder volume estimation reliable and valid? A systematic overview.". Scand J Urol Nephrol 32 (5): 325-30. PMID 9825394[e] Review at DARE
  9. 9.0 9.1 Nickel JC, Sander S, Moon TD (2008). "A meta-analysis of the vascular-related safety profile and efficacy of alpha-adrenergic blockers for symptoms related to benign prostatic hyperplasia.". Int J Clin Pract 62 (10): 1547-59. DOI:10.1111/j.1742-1241.2008.01880.x. PMID 18822025. PMC PMC2658011. Research Blogging.
  10. Gormley GJ, Stoner E, Bruskewitz RC, Imperato-McGinley J, Walsh PC, McConnell JD et al. (1992). "The effect of finasteride in men with benign prostatic hyperplasia. The Finasteride Study Group.". N Engl J Med 327 (17): 1185-91. PMID 1383816.
  11. Wilt TJ, Ishani A, Stark G, MacDonald R, Lau J, Mulrow C (1998). "Saw palmetto extracts for treatment of benign prostatic hyperplasia: a systematic review". JAMA 280 (18): 1604–9. PMID 9820264[e]
  12. Bent S, Kane C, Shinohara K, et al (2006). "Saw palmetto for benign prostatic hyperplasia". N. Engl. J. Med. 354 (6): 557–66. DOI:10.1056/NEJMoa053085. PMID 16467543. Research Blogging.
  13. Kaplan SA, Roehrborn CG, Rovner ES, Carlsson M, Bavendam T, Guan Z (2006). "Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder: a randomized controlled trial.". JAMA 296 (19): 2319-28. DOI:10.1001/jama.296.19.2319. PMID 17105794. Research Blogging.
  14. Tacklind J, Fink HA, Macdonald R, Rutks I, Wilt TJ (2010). "Finasteride for benign prostatic hyperplasia.". Cochrane Database Syst Rev 10: CD006015. DOI:10.1002/14651858.CD006015.pub3. PMID 20927745. Research Blogging.
  15. 15.0 15.1 Roehrborn CG, Siami P, Barkin J, Damião R, Major-Walker K, Nandy I et al. (2010). "The effects of combination therapy with dutasteride and tamsulosin on clinical outcomes in men with symptomatic benign prostatic hyperplasia: 4-year results from the CombAT study.". Eur Urol 57 (1): 123-31. DOI:10.1016/j.eururo.2009.09.035. PMID 19825505. Research Blogging.
  16. 16.0 16.1 16.2 McConnell JD, Roehrborn CG, Bautista OM, Andriole GL, Dixon CM, Kusek JW et al. (2003). "The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia.". N Engl J Med 349 (25): 2387-98. DOI:10.1056/NEJMoa030656. PMID 14681504. Research Blogging. Review in: ACP J Club. 2004 Jul-Aug;141(1):20
  17. 17.0 17.1 17.2 Lepor H, Williford WO, Barry MJ, Brawer MK, Dixon CM, Gormley G et al. (1996). "The efficacy of terazosin, finasteride, or both in benign prostatic hyperplasia. Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group.". N Engl J Med 335 (8): 533-9. PMID 8684407.