Benign prostatic hyperplasia (BPH) with bladder outlet obstruction has been shown to contribute to overall lower urinary tract symptoms (LUTS). The prevalence and severity of LUTS in aging men can be progressive. “The diagnosis and treatment of LUTS/BPH is important for healthcare and our aging society,” says Kevin T. McVary, MD. “The primary goal of treatment for BPH has been to alleviate bothersome LUTS that result from prostatic enlargement. More recently, treatment has further focused on the alteration of disease progression and prevention of complications that can be associated with BPH and LUTS.”
Studies have estimated the prevalence of moderate-to-severe LUTS to rise to nearly 50% by the time men reach their 80s. Although LUTS that are secondary to BPH are not often a life-threatening condition, the impact can be substantial on quality of life and should not be underestimated. Many patients are motivated to seek treatment from their physicians when bothersome symptoms become severe.
Revisiting Previous Guidelines
In 2011, the American Urological Association (AUA) released an updated clinical guideline on the treatment of BPH. Dr. McVary, who chaired the panel that developed the guidelines, says that it is the first update by the AUA since 2003. “It updates current guidance on diagnosing and treating LUTS/BPH, which can impact the quality of life,” he says. “The demographic of our society continues to age, meaning the number of elderly men who suffer from LUTS will increase. This will increase demands for treatment services and require the incorporation of evidence-based medicine in treatment plans.”
The update to the AUA guidelines (which are available at www.AUAnet.org) includes a detailed diagnostic algorithm to guide physicians in diagnosing and treating LUTS secondary to BPH (Figure). It also provides in-depth information on the basic management and more complicated management of BPH. The guidelines recommend that physicians treating men with suspected cases of LUTS should obtain a relevant medical history, assess symptoms using the AUA Symptom Index, and conduct a full physical examination that includes a digital rectal exam. Laboratory tests usually include a PSA test and a urinalysis to exclude infection or other causes for LUTS. Frequency and volume charts may also be useful in providing a diagnosis.
Exploring Treatment Options
A variety of pharmacologic classes are utilized to treat LUTS/BPH, including alpha-adrenergic antagonists (or alpha-blockers), 5-alpha-reductase inhibitors, anticholinergics, and phytotherapeutics, although the latter category is not endorsed in the document. “If drug therapy is considered, decisions will be influenced by coexisting overactive bladder symptoms and prostate size or serum PSA levels,” explains Dr. McVary. “Choosing the correct medical treatment for BPH can be complex, but clinicians should base treatment decisions on evidence-based data that are provided in the guidelines and in concert with patient wishes and concerns.”
Complementary and alternative medications, watchful waiting, surgical therapies, and lifestyle issues should also be addressed, according to the AUA guidelines. Additionally, the index patient age has been lowered from 50 to 45 to better guide physicians in treating younger men who may be experiencing LUTS.
“Another important addition to the guidelines includes cautionary statements about intraoperative floppy iris syndrome in cataract patients taking alpha-blockers to treat BPH,” Dr. McVary says. “Physicians should question patients about any planned cataract surgery prior to starting an alpha-blocker regimen. Men planning to undergo cataract surgery should avoid initiating alpha blockers until after their surgery has been completed. Men who are already taking the drugs should inform their ophthalmologists of their alpha-blocker regimen prior to cataract surgery to determine optimal treatment plans.”
As the male population continues to age, the health burden of BPH will be an important area for future research. The guidelines have identified several high-priority recommendations for future investigations (Table) with the hope of better defining the clinical phenotype of BPH, measuring disease severity and outcomes, and improving concepts for drug therapy, phytotherapies, behavioral and lifestyle interventions, and additional intervention therapies. Dr. McVary says that “progress in these areas has the potential to advance clinical care for patients beyond current strategies of symptom management.”
Readings & Resources (click to view)
American Urological Association. Guideline on the Treatment of Benign Prostatic Hyperplasia (BPH). Released February 3, 2011. Available at:http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/bph-management/chap_1_GuidelineManagementof(BPH).pdf.
McVary K. BPH: epidemiology and comorbidities. Am J Manag Care. 2006(Suppl):S122-S128.
Abrams P, Chapple C, Khoury S, Roehrborn C, de la Rosette J; International Scientific Committee. Evaluation and treatment of lower urinary tract symptoms in older men. J Urol. 2009;181:1779-1787.
Di Silverio F, Gentile V, Pastore AL, Voria G, Mariotti G, Sciarra A. Benign prostatic hyperplasia: what about a campaign for prevention? Urol Int. 2004;72:179-188.