BENIGN PROSTATIC HYPERPLASIA

Natural hx: 500 pts with symptomatic BPH who chose watchful waiting were initially classified as having mild, moderate, or severe BPH according to a sx questionnaire and followed for 4y. After 4y, 83% in mild group and 59% in moderate group still had mild or moderated sx; the remainder had progressed to severe or undergone surgery. Only 20% of pts with severe sx at baseline regressed to less sx. (J. Urol 157:10, 1997-JW)

Treatment:

I. Surgery
  1. Transurethral resection of the prostate ("TURP") --0.2% mortality, 5-10% morbidity; fails to resolve sx in 20%
  2. Laser therapy vs. TURP--Sympomatic outcomes were better with TURP (not stat. sig.) with no diff. in major complications in one randomized trial of 340 pts with BPH (J. Urol. 164:65, 2000--JW)
II. Medication
  1. Alpha-1 Adrenergic Blockers
  2. 5-alpha-reductase inhibitors
    1. Inhibit the conversion of testosterone to di-hydro testosterone
    2. Take months to have a noticeable effect
    3. Can cause decrease in volume of ejaculate, erectile dysfunction, decreased libido, and gynecomastia
    4. Finasteride (Proscar) 5mg PO QD
      1. Finasteride ass'd with lower (RR 0.43) risk of acute urinary retention and lower (RR 0.5) risk of need for surgery c/w placebo in a 4y trial in 3040 men with mod-severe BPH sx and enlarged prostate (NEJM 338:557, 1998--UW Pharm. Letter)
    5. Dutasteride (Avodart) 0.5mg PO QD
  3. Saw Palmetto (click link for info)
  4. Comparisons among different meds
    1. 1229 men with symptomatic BPH randomized to terazosin 10mg QD vs. finasteride 5mg QD vs. both vs. placebo x 1y and measured sx scores. Terazosin was sig. better than placebo and finasteride; finasteride was no better than placebo; combination tx no better than terazosin alone. Similar results with urine flow rates.
    2. 3047 men with moderate-to-severe BPH randomized to doxazosin, finasteride, both, or double-placebo.  Over mean 4y f/u, incidence of a composite clinical endpoint was sig. lower with combination therapy (5%) than with either monotherapy (10%).  (NEJM 349:2387, 2003--JW)