A group of clinicians summarized the most recent strategies for the management of lower urinary tract problems associated with benign prostatic hyperplasia (BPH) in a study titled “BPH update: medical versus interventional management” and published in the Canadian Journal of Urology.
Two clinicians from McMaster University and the University of Toronto, Canada, reviewed and summarized the management of this common disorder so that it can be easily identified by the general practitioner to provide the best possible care.
The authors recommend that a detailed history and physical exam is the most important step for a primary care physician to identify benign prostatic hyperplasia. Patients’ previous medical history such as diabetes and metabolic syndrome; their use of medication; and family history of BPH, together with habits such as fluids, caffeine, and alcohol intake, are key to identifying potential factors contributing to disease progression.
The first assessment should also include the International Prostate Symptom Score questionnaire developed by the American Urological Association to determine the symptomatic level, with scores from from 0 to 35. The second key step is the confirmation of benign prostatic hyperplasia by physical examination, including assessing the size of prostate by digital rectal examination.
Additionally, the Canadian Urological Association recommends testing for prostate-specific antigen (PSA) in all men considered for medical or interventional therapy who have a life expectancy beyond 10 years.
Upon a positive diagnosis, patients with mild symptoms are advised, in a first instance, to change their lifestyle habits – decreasing total daily fluid intake and reducing diuretic beverages intake, such as coffee, alcohol, and soft drinks.
When patients are treated with medicines, there are several options:, including the use of alpha-blockers or 5-alpha reductase inhibitors. Additionally, physicians may prescribe combination therapy along with alpha-blockers and 5-alpha reductase inhibitor for those who experience severe symptoms or fail to respond to a single therapy.
More recently, PDE5 inhibitors have been found to be another option for the treatment of BPH-associated symptoms. (PDE5 inhibitors were initially approved for the treatment of erectile dysfunction.)
Patients with refractory urinary retention and evidence of renal insufficiency need to undergo surgery as treatment, along with those who, despite treatment, continue to experience urinary symptoms that impact their life quality. While transurethral resection of prostate (TURP) has been considered the gold-standard surgical procedure for many years, newer strategies include laser therapies such as GreenLight photovaporization and holmium laser enucleation, both reported to achieve better outcomes in out-patient surgery, faster return to work, and no requirements to stop anti-coagulation.
A recent minimally invasive approach called Prostatic Urethral Lift (PUL) has resulted in several reports that show it improves lower urinary tract symptoms while preserving erectile function and lowering the risks of operative and postoperative complications.