Pathology and Medical Therapy of Benign Prostatic Hyperplasia
Pathology and Medical Therapy of Benign Prostatic Hyperplasia
6 JUNE 2011
Medical Bulletin
Introduction
Benign Prostatic Hyperplasia (BPH) is a progressive
condition characterised by prostate enlargement
accompanied by lower urinary tract symptoms (LUTS)1,2.
It contributes to, but is not the sole cause of LUTS. It is
well known that BPH and the resultant LUTS is very
common in elderly men3,4 and has a great impact on
the patients quality of life5. It was estimated that in the
male population, a histological prevalence at autopsy of
50% in men aged 50-60 years and of 90% over 80 years6
was seen. 75% of men > 50 years old had symptoms
arising from BPH, and 20-30% of men reaching 80 years
old required surgery 1,2. Despite the fact that BPH is
one of the commonest diseases that are managed by
urologists and it has a big impact on public health, the
aetiology and pathophysiology are still not yet clear.
Aetiology
Several mechanisms are now believed to be important
in the development and progression of BPH:
Tissue Remodelling
Hormonal Alterations
Inflammation
Metabolic Syndrome
Pathophysiology
Medical Therapy
Current strategies for treating men with LUTS are
watchful waiting, pharmacologic therapies and surgery
and this article will focus on medical therapy.
Phytotherapy
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with LUTS suggestive of BPH. They are considered
an appropriate option by the American Urological
Association (AUA) 34 and a large number of clinical
studies have demonstrated its efficacy. Typically
significant symptom relief could be obtained within
1-2 weeks of starting therapy and reduce symptom
scores by 5-8 points on the AUA-SI scale, with no clear
differences between the agents within the class 34,35.
Another important clinical use of alpha blockers is to
treat acute urinary retention. A randomised, double
blind, placebo-controlled study showed that starting
an alpha blocker after catheterisation in acute urinary
retention increased the chance of successful trial without
catheter (TWOC)36.
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Silodosin a newer selective alpha 1a receptor blocker
and effective for both storage and voiding symptoms in
BPH patients versus placebo, especially in patients with
severe symptoms (IPSS >= 20)50. Marks et al reported a
pooled analysis of two phase 3 randomised trials which
showed rapid significant improvement within 3-4 days
of initiation of silodosin51. The efficacy of the drug was
also supported by urodynamic effect studies which
showed improvement in peak flow rate, maximal bladder
capacity and reduction of detrusor overactivity 52.
Anticholinergics
PDE-5 Inhibitors
Conclusions
Medical therapy is indicated in patients with bothersome
lower urinary tract symptoms and alpha blockers are
usually the first option due to its rapid onset of action.
In those patients with persistent bothersome storage
symptoms, addition of an anti-muscarinic agent can
be considered after assessment with post void residual
volume measurement to rule out baseline urinary
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31.
32.
33.
34.
35.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
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60. Chapple CR, Roehrborn CG. A shifted paradigm for the further
understanding, evaluation and treatment of lower urinary tract
symptoms in men: focus on the bladder. Eur Urol 2006; 49: 651-659.
61. Kaplan SA, Roehrborn CG, Rovner ES et al. Tolterodine and
tamsulosin for treatment of men with lower urinary tract symptoms
and overactive bladder: a randomized controlled trial. JAMA 2006;
296: 2319-2328.
62. Chapple C, Gerschorn S, Abrams P et al. Tolterodine treatment
improves storage symptoms suggestive of overactive bladder in men
treated with alpha-blockers. Eur Urol 2009; 56: 534-541.
63. Chung DE, Te AE, Staskin DR, Kaplan SA. Efficacy and safety of
tolterodine extended release and dutasteride in male overactive
bladder patients with prostates > 30grams. Urology 2010; 75: 11441148.