Clinical Evidence Handbook A Publication of BMJ Publishing Group

Benign Prostatic Hyperplasia and Male Lower Urinary Tract Symptoms TOM McNICHOLAS, Lister Hospital, Stevenage, United Kingdom, and the University of Hertfordshire, Hatfield, United Kingdom ROGER KIRBY, The Centre, , United Kingdom

This is one in a series of Symptomatic benign prostatic hyperplasia with finasteride, and may be most effective chapters excerpted from (BPH) may affect up to 30 percent of men in in men with more severe symptoms of BPH the Clinical Evidence Handbook, published by their early 70s, causing urinary symptoms of or with hypertension. the BMJ Publishing Group, bladder outlet obstruction. • Caution: A drug safety alert has been London, U.K. The medical • Symptoms can improve without treat- issued on the risk of intraoperative floppy information contained ment, but the usual course is a slow pro- iris syndrome during cataract surgery with herein is the most accurate available at the date of gression of symptoms, with acute urinary tamsulosin and probably with other alpha publication. More updated retention occurring in 1 to 2 percent of men blockers. Persons taking an alpha blocker and comprehensive infor- with BPH per year. should inform their eye surgeon. mation on this topic may Alpha blockers improve symptoms com- 5α-reductase inhibitors (finasteride and be available in future print editions of the Clinical pared with placebo and more rapidly than dutasteride) improve symptoms (especially Evidence Handbook, as well as online at http:// www.clinicalevidence. bmj.com (subscription Clinical Questions required). Those who receive a complimentary What are the effects of medical treatments in men with BPH? print copy of the Clinical Beneficial 5α-reductase inhibitors Evidence Handbook from United Health Foundation Alpha blockers can gain complimentary What are the effects of herbal treatments in men with BPH? online access by register- Likely to be beneficial β-sitosterol plant extract ing on the Web site using the ISBN number of their Unknown effectiveness Pygeum africanum book. Rye grass pollen extract Unlikely to be beneficial Saw palmetto plant extracts What are the effects of surgical treatments in men with BPH? This clinical content con- Beneficial Transurethral resection of the prostate (improves symptoms compared forms to AAFP criteria for with no surgery) evidence-based continuing medical education (EB Likely to be beneficial Transurethral holmium laser enucleation of the prostate (may be as CME). See CME Quiz on effective as transurethral resection; however, it is unclear how it page 331. compares with no surgery or with other surgical techniques) Transurethral electrovaporization of the prostate (may be as effective as A collection of Clinical Evidence Handbook pub- transurethral resection; however, it is unclear how it compares with no lished in AFP is available surgery or with other surgical techniques) at http://www.aafp.org/ Transurethral microwave thermotherapy (improves symptoms compared afp/bmj. with no surgery; may be less effective than transurethral resection at improving symptoms) Unknown effectiveness Transurethral needle ablation (unclear how it compares with no surgery or with other surgical techniques)

BPH = benign prostatic hyperplasia.

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with longer duration of treatment) and descriptions incorrectly imply that urinary reduce the risk of complications of BPH symptoms in men arise from the prostate. compared with placebo, and are more effec- The acronym LUTS was introduced to avoid tive in men with larger . this. Increasingly, scientific communications • Caution: A drug safety alert has been on this syndrome use the term LUTS and issued on the risk of male breast cancer with avoid the use of the global term BPH. Nev- finasteride. Changes in breast tissue such as ertheless, BPH remains familiar to and is lumps, pain, or nipple discharge should be commonly used by family physicians, other promptly reported for further assessment. clinicians, and patients when searching for Saw palmetto plant extracts may be no clinical information and guidance. Clinically, more effective than placebo at improving the syndrome is characterized by symptoms symptoms. However, evidence was weak, such as urinary frequency, urgency, a weak and further good-quality long-term ran- and intermittent stream, needing to strain, a domized controlled trials are needed. sense of incomplete emptying, and nocturia. Compared with placebo, β-sitosterol plant It can lead to complications, including acute extract may improve symptoms of BPH in . the short term. We do not know whether rye grass pollen Incidence and Prevalence extract and Pygeum africanum are also ben- Estimates of the prevalence of symptomatic eficial, as few studies were found. BPH range from 10 to 30 percent for men Transurethral resection of the prostate in their early 70s, depending on how BPH is (TURP) improves symptoms of BPH more defined. than watchful waiting, and has been shown not to increase the risk of erectile dysfunc- Etiology and Risk Factors tion or incontinence. The mechanisms by which BPH causes • Some less invasive surgical techniques symptoms and complications are unclear, such as transurethral incision, laser ablation, although bladder outlet obstruction is an transurethral holmium laser enucleation, important factor. The best documented risk and transurethral electrovaporization seem factors are increasing age and normal testicu- to be as effective as TURP at improving lar function. symptoms. • TURP may be more effective at Prognosis improving symptoms and preventing re- Community- and practice-based studies sug- treatment compared with transurethral gest that men with LUTS can expect slow microwave thermotherapy, but causes more progression of symptoms. However, symp- complications. toms can wax and wane without treatment. • Transurethral microwave thermother- In men with LUTS secondary to BPH, rates apy reduces symptoms compared with sham of acute urinary retention range from 1 to 2 treatment or with alpha blockers, but long- percent per year. term effects are unknown. • We do not know whether transurethral SEARCH DATE: July 2009. needle ablation is effective. Author disclosure: Tom McNicholas and Roger Kirby have been reimbursed by Astellas, GSK, Pfizer, and MSD Definition for attending conferences, for lecturing, and for the expenses of research studies. Benign prostatic hyperplasia is defined histologically. Terms such as prostatism, Adapted with permission from McNicholas T, Kirby R. symptoms of BPH, and clinical BPH have Benign prostatic hyperplasia and male lower urinary tract symptoms (LUTS). Clin Evid Handbook. June 2012:321- previously been used to describe male lower 323. Please visit http://www.clinicalevidence.bmj.com for urinary tract symptoms (LUTS). These full text and references. ■

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