Prostate diseases--role of sex steroids and their inhibitors

The normal prostate as well as prostatic diseases are influenced by androgens. The exact reason for an altered and uncontrolled response to androgens, whether benign as in benign prostate hyperplasia (BPH) or malignant as in the case of prostate cancer (PC), is not known in detail. Nevertheless, restriction of androgen receptor activation by reduction of available androgens is of great clinical value in both diseases. In BPH the inhibition of the conversion of testosterone into 5α-dihydrotestosterone (DHT) by 5α-reductase (5AR) is highly efficient and used in general practice, while the situation in PC is more complex. Specific inhibition of 5AR does not provide as efficient relief of symptoms as general androgen deprivation therapy (ADT), and the use of 5ARI for PC prevention is still under debate. Further, the altered steroid metabolism in castration resistant prostate cancer (CRPC) together with the complex paracrine signalling between different androgen responsive cell types, make the development of more specific drugs targeting androgen receptor signalling both more relevant and challenging.

Serum lycopene concentration and prostate cancer risk: results from the Prostate Cancer Prevention Trial

BACKGROUND

Lycopene has been promoted for prostate cancer prevention, despite the inconsistency of scientific evidence.

METHODS

This nested case-control study examined whether serum lycopene was associated with prostate cancer risk among participants in the Prostate Cancer Prevention Trial, a placebo-controlled trial of finasteride for prostate cancer prevention. Presence or absence of cancer was determined by prostate biopsy, recommended during the trial due to elevated prostate specific antigen (PSA) level or abnormal digital rectal examination (DRE) and offered to all men at the trial end. There were 1,683 cases (461 Gleason score ≥ 7, 125 Gleason score ≥ 8) and 1,751 controls.

RESULTS

There were no associations of lycopene with prostate cancer risk. The odds ratios for a linear increase in lycopene (per 10 μg/dL) were 0.99 (95% CI: 0.94-1.04), 1.01 (0.94-1.08), and 1.02 (0.90-1.15) for Gleason 2 to 6, 7 to 10, and 8 to 10, respectively. In the placebo arm, a 10 μg/dL increase in lycopene was associated with a 7% (95% CI: 14-0) reduced risk of cancer diagnosed following an elevated PSA or abnormal DRE, which are cancers that best match those detected in screened populations. However, a 10 μg/dL increase in lycopene was also associated with an 8% (95% CI: 1-16) increased risk of cancer diagnosed without a biopsy prompt, which are cancers generally not detected. These findings were similar for low- and high-grade cancer.

CONCLUSION

This study does not support a role for lycopene in prostate cancer prevention.

IMPACT

Scientists and the public should understand that early studies supporting an association of dietary lycopene with reduced prostate cancer risk have not been replicated in studies using serum biomarkers of lycopene intake. Recommendations of professional societies to the public should be modified to reflect the likelihood that increasing lycopene intake will not affect prostate cancer risk.

Improving lower urinary tract symptoms in BPH

Benign prostatic hyperplasia (BPH) is one of the most common diseases to affect older men. Histological disease is present in more than 60% of men beyond their sixties, and more than 40% of men in this age group have lower urinary tract symptoms (LUTS). The prevalence increases with age. About one-fifth of patients with symptomatic disease who present to a doctor will eventually be treated surgically. The remainder will often be managed initially by active surveillance. The majority of these men suffer gradual progression of symptoms and increasingly require treatment. BPH is characterised by a spectrum of obstructive and irritative symptoms, known collectively as LUTS. Poor urinary flow and the sensation of incomplete bladder emptying are the two symptoms that correlate most closely with the eventual need for prostate surgery. Untreated, a significant number of men with BPH will eventually develop acute urinary retention. In addition tosymptom assessment, digital rectal examination can provide an estimate of prostate volume and exclude a palpable nodule suggestive of prostate cancer. PSA testing provides additional information about the risk of prostate cancer being present. Medical management of BPH is suitable for most patients with moderate symptoms. The two main evidence-based approaches are treatment with alpha1-blockers and 5alpha-reductase inhibitors (5-ARLs). Severely symptomatic patients may also respond to these drugs. Mild symptoms should usually be managed by active surveillance. Combination therapy with an alpha1-blocker and a 5-ARI is more effective than monotherapy in terms of symptom relief and prevention of progression.

Androgen regulation of prostate cancer: where are we now?

BACKGROUND

Androgens play an essential role in the development and differentiation of the prostate gland; their contribution to pathological conditions, such as benign prostatic hyperplasia and prostate cancer (PC), remains unclear.

AIM

We reviewed relationships between androgens and the prostate both in physiological and pathological conditions.

MATERIAL AND METHODS

A systematic search of published evidence was performed using Medline (1969 to September 2010).

RESULTS

Androgen-dependency of prostate growth is evident only in the hypogonadal condition, but not in the eugonadal state (the "saturation hypothesis"). There is unequivocal evidence that reducing androgen signaling to the hypogonadal range can reduce PC growth and patient symptoms. At physiological testosterone concentration there is no link between androgen levels and PC risk. In addition, different strategies of androgen deprivation (ADT) for advanced PC are only palliative and rarely cure patients. Preliminary evidence indicates that a low androgen milieu is associated with tumor aggressiveness. Transition to androgen-independence is complex and involves both selection and outgrowth of preexisting androgen resistant clones, as well as adaptative upregulation of genes that help the cancer cells to survive and grow after ADT. Because androgens are essential for the regulation of fat distribution, insulin sensitivity, and lipid and bone metabolism, recent publications have highlighted the concept that ADT may also be involved with an increase in overall, as well as cardiovascular, morbidity and mortality.

CONCLUSIONS

While ADT still represents a cornerstone for the palliative therapy of a small fraction of aggressive PC, a "misuse and/or abuse" of ADT should be avoided.

Effects of family history and genetic polymorphism on the cost-effectiveness of chemoprevention with finasteride for prostate cancer

PURPOSE

Improvement in the cost-effectiveness of chemoprevention for prostate cancer could be realized through the identification of patients at higher risk. We estimated the cost-effectiveness of prostate cancer chemoprevention across risk groups defined by family history and number of risk alleles, and the cost-effectiveness of targeting chemoprevention to higher risk groups.

MATERIALS AND METHODS

We developed a probabilistic Markov model to estimate costs, survival and quality adjusted survival across risk groups for patients receiving or not receiving chemoprevention with finasteride. The model uses data from national cancer registries, online sources and the medical literature.

RESULTS

The incremental cost-effectiveness of 25 years of chemoprevention with finasteride in patients 50 years old was an estimated $89,300 per quality adjusted life-year (95% CI $58,800-$149,800), assuming finasteride decreased all grades of prostate cancer by 24.8%. Among patients with a positive family history (without genetic testing) chemoprevention provided 1 additional quality adjusted life-year at a cost of $64,200. Among patients with a negative family history at $400 per person tested, the cost-effectiveness of genetically targeted chemoprevention ranged from $98,100 per quality adjusted life-year when limiting finasteride to individuals with 14 or more risk alleles, to $103,200 per quality adjusted life-year when including those with 8 or more risk alleles.

CONCLUSIONS

Although there are small differences in the cost-effectiveness of genetically targeted chemoprevention strategies in patients with a negative family history, genetic testing could reduce total expenditures if used to target chemoprevention for higher risk groups.

[Cost-effectiveness of the combination therapy of dutasteride and tamsulosin in the treatment of benign prostatic hyperlasia in Spain]

OBJECTIVES

to evaluate the incremental cost-effectiveness ratio (ICER) of the combination therapy with dutasteride and tamsulosin (DUT+TAM) as initiation treatment versus the most used drug in Spain, tamsulosin (TAM), in the treatment of moderate to severe benign prostatic hyperplasia (BPH) with risk of progression.

METHODS

a semi-Markov model was developed using 4-year and 35-year time horizons and from the Spanish National Healthcare Service perspective. Data were obtained from the CombAT trial. Effectiveness was measured in terms of quality adjusted life years (QALYs). Health care resources were defined by an experts' panel, and unitary costs were obtained from published Spanish sources. Pharmacologic cost is expressed in PTP(WAT); in the case of TAM, the generic price is used, in the case of DUT+TAM the price of a fixed dose combination is used. Costs are expressed in 2010 Euros.

RESULTS

combination therapy with DUT+TAM produces an incremental effectiveness of 0.06QALY at year 4 and 0.4QALY at year 35. DUT+TAM represents an incremental cost of € 810.53 at 4 years and € 3,443.62 at 35 years. Therefore, the ICER for DUT+TAM versus TAM is € 14,023.32/QALY at year 4 and € 8,750.15/QALY at year 35.

CONCLUSIONS

initiation treatment with DUT+TAM represents a cost-effective treatment versus TAM, the most used treatment in Spain, due to the fact the ICER is below the threshold that usually allows a technology to be considered as cost-effective.

[Dutasteride in the treatment of benign prostatic hyperplasia: an update]

Benign prostatic hyperplasia (BPH) is a common disease in older men. At present, 5alpha reductase inhibitor-based medication, preferred by most BPH patients as the first-choice therapy, is taking place of traditional transurethral resection of the prostate. This article presents an update of the researches on the treatment of BPH with dutasteride--a novel 5 alpha-reductase inhibitor.

[Diagnosis and treatment of urolithiasis in combination with infravesical obstruction in presenile and senile patients]

The analysis of the results of examination and treatment of 510 urolithiasis patients with organic infravesical obstruction (IVO) treated in the urological clinic of M. F. Vladimirsky Moscow Regional Research Clinical Institute and in the urological department of Zhukovsky city hospital from 1995 to 2009 made it possible to arrive at the following conclusions: the above patients have obstruction symptoms in 100% cases, irritative symptoms--in more than 2/3 of the patients; combined use of low invasive, endoscopic and open methods reestablishes urodynamics of the lower urinary tract in more than 90% patients; the decision on the treatment policy and techniques depends on severity of clinical symptoms caused by IVO and urolithiasis as well as disturbance of upper and lower urinary tract urodynamics. In adequate choice of the patients and correct indications combined use of low invasive, endoscopic and open methods provides good treatment effect in patients with IVO and urolithiasis.

Male lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH)

Male lower urinary tract symptoms, benign prostatic hyperplasia, enlargement of the prostate, and bladder outlet obstruction are common among aging men and will increase in socioeconomic and medical importance at a time of increased life expectancy and aging of the baby boomer generation. This article reviews the epidemiology, management, and therapeutic options for these conditions. In patients bothered by moderate to severe symptoms, providers can make educated and differential choices between several classes of drugs, alone or in combination, to treat effectively and improve the symptoms in most men. Despite the efficacy of medical therapy, there will be patients who require referral to a urologist either early, to rule out prostate cancer and other conditions, or later, after initial medical therapy and lifestyle management has failed. Perhaps as many as 30% of patients fail to achieve sufficient symptom improvement with medication, lifestyle adjustment, and fluid management, and may require more invasive or surgical treatment options.

[The effects of dutasteride on voiding and storage symptoms in men with benign prostatic hyperplasia]

We investigated the effects of dutasteride on voiding and storage symptoms by a post-hoc analysis from two randomized, placebo-controlled, parallel-group studies (Japanese phase II study and phase III study) which assessed the efficacy and safety of dutasteride in Japanese men with benign prostatic hyperplasia (BPH). Men aged 50 years and older, with a prostate volume of 30 cc or greater, an International Prostate Symptom Score (IPSS) of 8 or higher and maximal urinary flow rate of 15 ml/sec or lower were randomized to placebo or dutasteride groups. The number of subjects for the placebo and dutasteride groups was respectively 72 and 72 in the phase II study, and 185 and 193 in the phase III study. Questions 1, 3, 5 and 6 of IPSS were related to voiding symptoms, and Questions 2, 4 and 7 were related to storage symptoms. Changes between pre- and post-treatments were evaluated. In the phase II study, dutasteride significantly improved voiding symptoms and numerically improved storage symptoms compared with the placebo at week 24. In the phase III study, dutasteride significantly improved voiding and storage symptoms compared with the placebo after 52 weeks. These consistent results suggest that dutasteride is effective for both voiding and storage symptoms in Japanese men with BPH.

Biology and natural history of prostate cancer and the role of chemoprevention

Androgens not only play an important role in the development and function of the prostate but they are also intimately involved in the development and progression of prostate cancer (PCa). Within the prostate, testosterone is converted to the more potent androgen dihydrotestosterone (DHT) via the action of 5α-reductase enzymes. DHT is the primary prostatic androgen and promotes the growth and survival of normal, hyperplastic and malignant prostate tissues. Throughout the different stages of PCa [prostatic intraepithelial neoplasia (PIN), localised, recurrent, and metastatic] there is an increase in expression of 5α-reductase enzymes, particularly in localised high-grade carcinoma. Specifically inhibiting 5α-reductase may reduce the production of DHT in the prostate while maintaining other endogenous hormone levels. Clinical studies have shown significant PCa risk reduction by blocking this pathway with 5α-reductase inhibitors (5ARIs). However, this comes at a risk, albeit low, with sexual side effects, gynaecomastia and cardiac failure. In addition, one study has shown a slight, but significant, risk of high-grade PCa. The currently available evidence does not support the routine use of 5α-reductase inhibitors to prevent PCa in the general population. It could, however, be considered as an individual option for high-risk or concerned patients with appropriate education from the prescribing provider.

Effect of finasteride on the sensitivity of PSA to detect prostate cancer in rebiopsy series

OBJECTIVES

To evaluate, in a prospective study, the diagnostic accuracy of PSA in patients with a prior negative prostate biopsy who were given finasteride for 6 months.

MATERIALS AND METHODS

91 men with prior negative biopsy findings, including HGPIN and excluding ASAP, were instructed to take finasteride for 6 months. All patients were evaluated at study onset and after 6 months by clinical examination, digital rectal examination (DRE), International Prostate Symptom Score (IPSS) and National Institutes of Health Chronic Prostatitis Symptom Index (NHI-CPSI). Prostate biopsy was repeated at 6 months. PSA levels were measured at baseline and after 1, 3 and 6 months. We calculated the receiver operating characteristics (ROC) curve of PSA under the effect of finasteride for detecting prostate cancer.

RESULTS

The median PSA level decreased similarly both in those with prostate cancer and in those without findings of cancer. There was no statistically significant difference between the two groups. The areas under the ROC curve (AUC) of PSA at study onset and after 6 months of therapy with finasteride were, respectively, 0.48 (95% CI 0.36-0.61) and 0.54 (95% CI 0.42-0.66). There was no statistically significant difference between the two areas.

CONCLUSIONS

The results of our study show that PSA itself has a low diagnostic accuracy for detecting prostate cancer in men with prior negative prostate biopsy findings. Finasteride does not seem to improve the accuracy of PSA in this particular population of patients.

Benign prostatic hyperplasia and prostate cancer: an overview for primary care physicians

Benign prostatic hyperplasia (BPH) and prostate cancer (CaP) are major sources of morbidity in older men. Management of these disorders has evolved considerably in recent years. This article provides a focused overview of BPH and CaP management aimed at primary care physicians. Current literature pertaining to BPH and CaP is reviewed and discussed. The management of BPH has been influenced by the adoption of effective medical therapies; nonetheless, surgical intervention remains a valid option for many men. This can be accomplished with well-established standards such as transurethral resection of the prostate or with minimally invasive techniques. Prostate cancer screening remains controversial despite the recent publication of two large clinical trials. Not all prostate cancers necessarily need to be treated. Robot-assisted prostatectomy is a new and increasingly utilised technique for CaP management, although open radical retropubic prostatectomy is the oncological reference standard. The ageing of the population of the developed world means that primary care physicians will see an increasing number of men with BPH and CaP. Close collaboration between primary care physicians and urologists offers the key to successful management of these disorders.

[Effect of one month treatment with dutasteride on transurethral resection of the prostate]

OBJECTIVE

Evaluate the effect of dutasteride in perioperative bleeding during Transurethral Resection of Prostate (TURP).

MATERIALS AND METHODS

Forty consecutive patients with criteria for TURP were included. Finasteride/dutasteride use, renal impairment, prostate < 30 cc, age <50 were excluded. Patients were divided in 2 groups. Group 1: 24 consecutive patients treated with dutasteride 0.5 mg/day/30-days prior TURP. Group 2: 16 without treatment. Prostatic volume, difference in hemoglobin pre/post TURP, duration and amount of resected tissue were recorded. Surgeon was blinded.

STATISTICAL ANALYSIS

Multiple linear regression, Mann-Whitney and student t-tests were used.

RESULTS

In group 1, 33% (8) improved their lower urinary tract symptoms and skipped TURP. Mean Hemoglobin loss difference between groups was 0.11 gr/dl (CI 95% -0.55; 0.77, p=0.88). There was no statistical difference among variables. No positive or negative predictive values in the linear regression model.

CONCLUSION

Dutasteride did not significantly impact the studied variables in these non randomized and small sample size settings.

Impact of pharmacotherapy on the incidence of transurethral prostatectomy for benign prostatic hyperplasia and the implications for surgical training

Medical therapy has become first line treatment for Benign Prostatic Hypertrophy (BPH) and in many cases TURP may no longer be required. Proof and quantification of this evolution in practice has been somewhat elusive and provided the principle impetus for this study. This is a retrospective study of BPH management in Republic of Ireland from 1995 to 2008. National treatment databases were sourced for numbers undergoing TURP and pharmacotherapy prescribing data was obtained from individual pharmaceutical companies. A total of 28,240 TURP's were performed nationally between 1995 and 2008. TURP's performed annually, decreased by 1,494 (51%), alpha-blocker prescriptions increased from 8,710 to 302,159 units and the number of urology trainees increased by 10 (60%). Clear association between decreases in TURP's and increases in pharmacotherapy for BPH is demonstrated. Implications on training likely exist and will require proper evaluation in order to maintain future standards in this surgical practice.

Differential expression of steroid 5alpha-reductase isozymes and association with disease severity and angiogenic genes predict their biological role in prostate cancer

The biological role of steroid 5alpha-reductase isozymes (encoded by the SRD5A1 and SRD5A2 genes) and angiogenic factors that play important roles in the pathogenesis and vascularization of prostate cancer (PC) is poorly understood. The sub-cellular expression of these isozymes and vascular endothelial growth factor (VEGF) in PC tissue microarrays (n=62) was examined using immunohistochemistry. The effect of SRD5A inhibition on the angiogenesis pathway genes in PC was also examined in prostate cell lines, LNCaP, PC3, and RWPE-1, by treating them with the SRD5A inhibitors finasteride and dutasteride, followed by western blot, quantitative PCR, and ELISA chip array techniques. In PC tissues, nuclear SRD5A1 expression was strongly associated with higher cancer Gleason scores (P=0.02), higher cancer stage (P=0.01), and higher serum prostate specific antigen (PSA) levels (P=0.01), whereas nuclear SRD5A2 expression was correlated with VEGF expression (P=0.01). Prostate tumor cell viability was significantly reduced in dutasteride-treated PC3 and RWPE-1 cells compared with finasteride-treated groups. Expression of the angiogenesis pathway genes transforming growth factor beta 1 (TGFB1), endothelin (EDN1), TGFalpha (TGFA), and VEGFR1 was upregulated in LNCaP cells, and at least 7 out of 21 genes were upregulated in PC3 cells treated with finasteride (25 muM). Our findings suggest that SRD5A1 expression predominates in advanced PC, and that inhibition of SRD5A1 and SRD5A2 together was more effective in reducing cell numbers than inhibition of SRD5A2 alone. However, these inhibitors did not show any significant difference in prostate cell angiogenic response. Interestingly, some angiogenic genes remained activated after treatment, possibly due to the duration of treatment and tumor resistance to inhibitors.

[Treatment of prostatic adenoma]

We used lymphotropic therapy in addition to standard treatment in 116 of 232 patients with benign prostatic hyperplasia. The effect was evaluated in the course of treatment and followed up for a year. Improvement in general condition of the patients, symptoms of infravesical obstruction, size of the prostate, urinary flow rate demonstrated high efficacy of lymphotropic therapy leading to a higher rate of persistent remission and higher quality of life.

Effect of dutasteride, tamsulosin and the combination on patient-reported quality of life and treatment satisfaction in men with moderate-to-severe benign prostatic hyperplasia: 4-year data from the CombAT study

OBJECTIVE

To investigate the effect of combination therapy with dutasteride plus tamsulosin compared with each monotherapy on patient-reported health outcomes over 4 years in men with moderate-to-severe lower urinary tract symptoms (LUTS) because of benign prostatic hyperplasia (BPH).

METHODS

CombAT was a 4-year international, double-blind, randomised, parallel-group trial in men (n = 4844) with moderate-to-severe symptoms of BPH and at increased risk of disease progression [age > or = 50 years, International Prostate Symptom Score (IPSS) > or = 12, prostate volume > or = 30 cc, serum prostate-specific antigen > or = 1.5 ng/ml to < or = 10 ng/ml and maximum urinary flow rate 5-15 ml/s with minimum voided volume > or = 125 ml]. Subjects were randomised to receive 0.5 mg dutasteride, 0.4 mg tamsulosin or the combination once daily for 4 years. The primary endpoint at 4 years was the time to event and proportion of subjects with acute urinary retention or undergoing BPH-related prostate surgery. Secondary endpoints included the health-outcomes measures, BPH Impact Index (BII), IPSS question 8 (IPSS Q8) and the Patient Perception of Study Medication (PPSM) questionnaire.

RESULTS

At 4 years, combination therapy resulted in significantly superior improvements from baseline in BII and IPSS Q8 than either monotherapy; these benefits were observed from 3 months onwards compared with dutasteride and from 9 months (BII) or 12 months (IPSS Q8) onwards compared with tamsulosin. Also at 4 years, the PPSM questionnaire showed that a significantly higher proportion of patients was satisfied with, and would request treatment with, combination therapy compared with either monotherapy.

CONCLUSIONS

Combination therapy (dutasteride plus tamsulosin) provides significantly superior improvements in patient-reported quality of life and treatment satisfaction than either monotherapy at 4 years in men with moderate-to-severe BPH symptoms.

[Androgen-deprivation therapy in prostate cancer: clinical evidence and future perspectives]

Androgens are involved in the development and progression of prostate cancer even if the mechanism is not well-recognized. For this reason androgen-deprivation therapy remains a milestone for the treatment of patients with advanced and metastatic disease and, in the last years, in conjunction with radiotherapy and surgery in locally advanced tumors. Alternative options, such as intermittent deprivation suppression, seem to be promising in terms of clinical benefits and toxicity profile. However, current therapies present side effects, such as testosterone surge with consequent clinical flare-up, metabolic syndrome and hormone-resistance, which develops after a variable number of years. Novel therapies such as LH-RH antagonists and prolonged depot LH-RH analogues have been developed in order to avoid clinical flare-up and testosterone microsurges. Novel androgen synthesis inhibitors, such as abiraterone acetate and MDV3100, have been recently discovered and tested as promising hormonal second-line agents in patients with castration-resistant prostate cancer. Finally, long-term side effects from androgen deprivation, such as osteoporosis, sarcopenic obesity and cardiovascular morbidity should be carefully monitored and properly treated.

STEP: simplified treatment of the enlarged prostate

We propose a simple and practical approach to the identification, evaluation and treatment of lower urinary tract symptoms (LUTS) resulting from an enlarging and obstructive prostate. The proposed Simplified Treatment for Enlarged Prostate (STEP) plan is a logical guide to patient management by the primary care provider (PCP). Symptoms of enlarged prostate (EP) are common and may frequently progress into a condition with profound adverse effects on quality of life. Despite the high prevalence, EP is underdiagnosed and undertreated. This situation may result from patient- and provider-related issues. Assessment of symptoms of EP should be initiated with a discussion of LUTS. Evaluation includes a focused history, physical examination and selected laboratory tests. Certain factors put the symptomatic patient at risk for disease progression; however, not all factors can be readily evaluated in the PCP setting. The serum prostate-specific antigen (PSA) level acts both as an indicator of prostatic size and a screening tool for prostatic cancer, and thereby provides an important tool for PCPs. The STEP plan is a logical guide to patient management. Step 1, watchful waiting, is appropriate in patients with symptoms that are not bothersome. If symptoms cause bother, the initiation of an alpha-blocker (AB) in step 2, provides relatively rapid symptom improvement. Patients with bothersome symptoms and a PSA > or = 1.5 ng/ml are at risk for progression and consideration should be given to combination treatment with an AB and a 5alpha-reductase inhibitor (step 3). Patients with refractory symptoms should be referred to a urologist (step 4). Identification, evaluation and management of EP are within the domain of the primary care setting. The STEP approach provides a simple and practical framework for PCPs to manage most men with symptoms of EP.

Glutathione S-transferase (GST) gene variants and risk of benign prostatic hyperplasia: a report in a North Indian population

Glutathione S-transferases may be over expressed in benign prostate hyperplasia (BPH) but association of GST polymorphism with susceptibility to the disease is unclear. The objective of this study was to determine relationships between polymorphisms in the GSTM1, T1 and P1 genes with risk of symptomatic BPH and response to standard therapy. The study population comprised 160 symptomatic BPH patients with BPE (benign prostatic enlargement) and LUTS (lower urinary tract symptoms) and 200 age-matched controls. Patient inclusion criteria were: age>50 years; prostate size>30 cm3; AUA (American Urological Association) score>7; and PVR volume≤200 ml. Patients were treated with alpha-adrenergic blockers and 5alpha-reductase inhibitors for 6 months and subdivided based on significant improvement in parameters between pre and post combined therapy. The GSTT1 and GSTM1 variants genotyped with multiplex-PCR, whereas GSTP1 polymorphisms were determined with PCR-RFLP (polymerase chain reaction- restriction fragment length polymorphism). We observed a lack of any association with GSTT1 (p=0.45, OR=2.25, 95% CI=1.71-2.22) and GSTP1 (p=0.92 and 0.99) genes. There was a significant positive association with null alleles of the GSTM1 (p=0.000, OR=2.24, 95%CI =1.46-3.42) gene. Combined analysis of the three genotypes demonstrated further increase in the risk of symptomatic BPH (p=0.009, OR=8.31 95%CI=1.71-40.4). Polymorphisms of GST genes were not associated with rates for responders and non-responders. GSTM1 deletion is significantly associated with the increased risk of symptomatic BPH, but none of the GST polymorphisms appears associated with response to standard BPH therapy.