The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group

Dutasteride Improves Objective and Subjective Disease Measures in Men With Benign Prostatic Hyperplasia and Modest or Severe Prostate Enlargement

PURPOSE

We determined whether the effect of dutasteride for benign prostatic hyperplasia is influenced by baseline prostate volume using data from 3 phase III clinical trials.

MATERIALS AND METHODS

Patients randomized to dutasteride or placebo in the double-blind portion of the phase III studies were eligible to receive 0.5 mg dutasteride daily in a 2-year open label extension in dutasteride/dutasteride and placebo/dutasteride groups. Patients were prospectively stratified according to baseline prostate volume 30 to less than 40 and 40 cc or greater.

RESULTS

In patients treated with dutasteride throughout the study (dutasteride/dutasteride group) the mean reduction in prostate volume from baseline to month 48 was 30.3% in those with a baseline prostate volume of 30 to less than 40 cc and 26.2% in those with a prostate volume of 40 cc or greater. Mean improvements in peak urinary flow from baseline to month 48 were 2.7 ml per second regardless of baseline prostate volume. Improvements in the American Urological Association symptom index score were 6.3 in men with a prostate volume of 30 to less than 40 cc and 6.5 in those with a prostate volume of 40 cc or greater. No significant relationships between treatment effect and baseline prostate volume were observed for these parameters. In dutasteride/dutasteride treated patients the risk of acute urinary retention was decreased by 60% in those with a prostate volume of 30 to less than 40 cc and 55% in those with a prostate volume of 40 cc or greater vs values in placebo/dutasteride treated patients (p = 0.036 and <0.001, respectively). The corresponding values for benign prostatic hyperplasia related surgery were 27% and 48% (p = 0.35 and <0.001, respectively).

CONCLUSIONS

This analysis demonstrates that dutasteride significantly improves objective (prostate volume and peak urinary flow) and subjective (symptom scores) measures even in patients with only a slightly enlarged prostate (30 to less than 40 cc). The risks of acute urinary retention and benign prostatic hyperplasia related surgery were decreased regardless of baseline prostate volume.

Clinical Approach to the Prostate: An Update

Prostatic disease continues to present clinicians with challenges. Although giant strides have been made in the medical and surgical management of benign prostatic hyperplasia, many fundamental questions about its pathogenesis, progression, and treatment efficacy remain unanswered. Prostate cancer also continues to be an area in which progress is needed despite major recent advancements. Numerous debates that include the value of prostate-specific antigen screening and appropriate roles for each of the numerous therapeutic modalities await resolution. For millions of patients who suffer from prostatitis, a major breakthrough is yet to come. Current treatment regimens for prostatitis remain ineffective at best. Contemporary approaches to the pathogenesis, diagnosis, and treatment of benign prostatic hyperplasia, prostate cancer, and prostatitis are discussed in this review.

The Placebo Effect in the Pharmacologic Treatment of Patients with Lower Urinary Tract Symptoms

OBJECTIVES

We reviewed placebo responses in randomised controlled trials (RCTs) for pharmacologic treatment of lower urinary tract symptoms (LUTS), including urinary incontinence (UI), overactive bladder, and benign prostatic hyperplasia. Review papers on placebo effects in non-urologic disorders were assessed to compare the magnitude of placebo responses in drugs for LUTS with those reported for other diseases.

METHODS

Data were retrieved from registration trials for LUTS drugs on the Web sites of the Food and Drugs Administration and the European Medicines Agency. Reviews were retrieved from Medline using the MeSH term "placebo effect" (English language; published between 1990 and 2005).

RESULTS

Placebo treatment of LUTS yields reductions in incontinence episodes (IEs) ranging from 32% to 65%, whereas prostate or UI symptom scores are reduced by 9-34%. Genuine drugs decrease IEs by 45-77% and symptom scores by 22-45%. Placebo responses are much lower when objective changes in voided volume or peak flow rate are assessed.

CONCLUSIONS

The placebo effect in LUTS has a strong behavioural component as patients become aware of their voiding habits and potential risk factors. Symptom severity, treatment naivety, study duration, and interaction with health care providers may also influence it. Proper patient selection, study duration, and objective and subjective outcome measures may better separate genuine treatment effects from artefacts. Observational studies with patients representative for real-life situations and covering a sufficient period of time could allow for better understanding of RCT results and their applicability in clinical practice.

Acute urinary retention: who is at risk and how best to manage it?

In recent years, we have begun to understand the progressive nature of benign prostatic hyperplasia. By careful analysis of population studies and clinical trials, we can determine the factors most likely to predict progression to one of its most distressing complications, acute urinary retention. Acute urinary retention is a common urologic emergency and causes significant suffering, although rarely has it any serious consequences. Using our knowledge regarding the progression of benign prostatic hyperplasia, new treatment modalities are being assessed for their effectiveness at halting progression and ultimately preventing this distressing condition.

Use of 5α-reductase inhibitors to prevent benign prostatic hyperplasia disease

A histologic change in the prostate, benign prostatic hyperplasia (BPH), is a normal part of aging. However, BPH disease, defined here as a life-altering urinary condition caused by BPH requiring prompt medical intervention, is a serious medical disorder associated with major complications, surgical intervention, and severe lifestyle interference. BPH disease is preventable. The rationale for BPH disease prevention rests on four pillars of evidence: (1) BPH disease generally is a progressive disorder; (2) complications and severe lifestyle interference from BPH disease are common and serious; (3) men at greatest risk of BPH disease can be identified using prostate-specific antigen (PSA) level higher than 1.5 ng/mL as a surrogate marker for an enlarged prostate; and (4) 5alpha-reductase inhibitors (5ARIs) reduce the primary androgen responsible for prostate growth (dihydrotestosterone), shrink the prostate, and arrest the disease process regardless of symptom status. Thus, we now can identify men with an enlarged prostate at risk for BPH disease who may be candidates for preventive therapy with 5ARIs, regardless of urinary symptoms or bother.

Finasteride targets prostate vascularity by inducing apoptosis and inhibiting cell adhesion of benign and malignant prostate cells

BACKGROUND

This study investigated the effects of finasteride, a 5alpha-reductase inhibitor, clinically used for the treatment of benign prostatic hyperplasia (BPH) on prostate tumor vascularity, apoptosis, and cell adhesion in situ and in vitro.

METHODS

Prostate specimens from BPH patients treated with finasteride for 1-12 months (n = 13), or without finasteride treatment (n = 14), were evaluated for apoptosis (TUNEL assay), microvessel density (Factor VIII), and prostate specific antigen (PSA) immunoreactivity. In vitro, the effect of finasteride was investigated in benign prostate cells, BPH-1, and its tumorigenic derivatives, CAFTD-01 and CAFTD-03, using Hoechst staining and cell adhesion assays.

RESULTS

A significant increase in the apoptotic index, and reduced microvessel density and PSA expression were detected in prostates from finasteride-treated patients, compared to controls (P < 0.01). In vitro finasteride led to a significant decrease in prostate epithelial cell adhesion (P < 0.05).

CONCLUSIONS

Finasteride can induce prostate apoptosis and reduce tissue vascularity by inhibiting epithelial cell adhesion. This evidence supports that finasteride has apoptotic and anti-angiogenic effects against benign and malignant prostate.

Effect of dutasteride on the symptoms of benign prostatic hyperplasia, and patient quality of life and discomfort, in clinical practice

OBJECTIVE

To assess the improvements in symptoms, quality of life (QoL), discomfort and satisfaction in patients with symptomatic benign prostatic hyperplasia (BPH) treated with dutasteride in clinical practice.

PATIENTS AND METHODS

In a prospective, multicentre open-label study, we evaluated the efficacy and safety in clinical practice of dutasteride, 0.5 mg/day for 24 weeks, in patients with symptomatic BPH. The primary endpoint was the proportion of patients achieving at least a 3-point decrease from baseline in the International Prostate Symptom Score (IPSS) after 24 weeks of treatment. The secondary endpoints included changes from baseline in measures of QoL (IPSS item 8 and BPH Impact Index score, BII), and patient discomfort and satisfaction (visual analogue scales, VAS) at 12 and 24 weeks.

RESULTS

Of the 366 patients assessed, 72.5% achieved at least a 3-point reduction in IPSS at 24 weeks; the IPSS decreased from 15.3 at baseline to 10.2 at 12 weeks, and to 9.1 at 24 weeks. There were significant (P < 0.001) decreases in all the individual IPSS items at 12 and 24 weeks, with more marked improvements in voiding symptoms than storage symptoms. There were also significant (P < 0.001) improvements in the BII and VAS scores for patient discomfort and satisfaction at both times.

CONCLUSIONS

Dutasteride treatment for 24 weeks significantly improved BPH symptoms, QoL and patient discomfort and satisfaction, and was well tolerated in clinical practice.

Medical and minimally invasive therapies for the treatment of benign prostatic hyperplasia

Over the last decade, management of benign prostatic hyperplasia (BPH) has changed with a substantial decrease in the use of transurethral prostatectomy (TURP) and a simultaneous increase in the use of medical therapy and minimally invasive surgical therapy (MIST). The goal of management of this chronic progressive condition is not only to provide relief of lower urinary tract symptoms (LUTS) but also to reduce the lifetime risk of adverse outcomes. Recent clinical evidence has demonstrated a clear role for medical therapy, particularly with 5-alpha-reductase inhibitors (5ARIs) either alone or in combination with alpha-blockers, to reduce the risk of acute urinary retention and need for surgery and provide symptom relief. Clinical data on MISTs also indicate a more pronounced short-term effect; however, the long-term durability of these therapies remains uncertain. Minimally invasive surgical therapies confer treatment benefits in a single 1-h treatment session under local anesthesia. Recovery times and adverse events are improved compared with TURP, but issues such as hematuria, prolonged catheterization, urinary tract infection and retreatment remain commonly reported issues. Today, urologists are faced with the challenge of identifying the most appropriate treatment option for the long-term management of BPH. The initial choice for any given patient will depend on his presenting circumstances and the influence of treatment risks on these circumstances. Providing patients with informed treatment decisions is a key element of management.

The Heart of Drug Discovery and Development: Rational Target Selection

Critical to the discovery and development of drugs and vaccines is the rational selection of biochemical, immunologic or molecular targets. To understand the rationale for target selection, we review strengths and weaknesses of the four main approaches: whole animal disease models; molecular targeting; epidemiology/observation studies, and genomics. After classifying diseases into those with a relatively stable pathophysiology (e.g., hypertension and gout) versus those with an unstable pathophysiology (e.g., AIDS and influenza) to aid in understanding target selection, we provide examples of successful and unsuccessful selection of drug and vaccine targets, focusing on the molecular and epidemiological/observational approaches. We discuss the reasons that molecular targeting has led to successful control of many diseases, whereas the epidemiological/observational approach has had a checkered history. We also assess the potential power of the genomic approach, specifically the curative versus controlling/preventive strategies. With combined genetic and molecular approaches and judicious use of whole animal models and properly performed epidemiology/observation studies to select the appropriate targets, the future for controlling, preventing and even curing many diseases is very bright indeed.

Medical Treatment of Benign Prostatic Hyperplasa Where do we stand in 2004?

The three factors responsible for the lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) are the prostate itself, the bladder and the central nervous sys-tem. The prostate is responsible for obstruction through its physi-cal mass (static component) and its smooth muscle contraction (dynamic component). The bladder and spinal cord are mainly responsible for irritative (storage) symptoms.

First-line treatment for symptomatic benign prostatic hyperplasia: is there a particular patient profile for a particular treatment?

When the range of treatment options for benign prostatic hyperplasia (BPH) is as broad as the BPH spectrum of symptoms, how should urologists and their patients choose the best initial treatment? Treatment goals should include reducing both lower urinary tract symptoms and relieving associated morbidities, such as urinary retention, persistent gross hematuria, recurrent infections, bladder stones, or renal insufficiency-which are all indications for surgery. However, if one views BPH as a chronic and progressive disease, should a primary goal of BPH management be the prevention of the BPH-associated morbidities? The goal of this paper is to provide a literature update regarding various treatment options in the setting of initial treatment for symptomatic BPH. Novel approaches to BPH management are discussed. In all cases, the risks and benefits of each treatment need to be considered and discussed with the patient; the decision is ultimately up to the patient and his urologist.

Evidence of a novel biomarker, alphas1-Casein, a milk protein, in benign prostate hyperplasia

Benign prostate hyperplasia (BPH) is a common disease in elderly men. Although it is a non-malignant disease, it has a significant detrimental impact on the quality of life in patients with late-stage disease. Owing to the lack of specific markers, diagnosis of early-stage BPH has been proven unsuccessful. Recently, using two-dimensional electrophoresis, we identified a group of prostatic secretory proteins that are specifically produced by BPH cells (Xu et al., Electrophoresis 2003; 24: 1311). In this study, we investigated the potential diagnostic value of one of the secretory proteins, alphas1-Casein, in BPH by inmmunohistological staining of normal, BPH and prostate cancer tissues. We found that 90% (20 out of 22) of BPH tissues showed moderate to strong alphas1-Casein protein expression whereas none of the normal tissues (0 out of 10) and less than 10% of the prostate cancer tissues (3 out of 30) showed similar staining intensity. Our results suggest that alphas1-Casein may be a potential biomarker for early identification of BPH patients.

Relationship between serum prostate-specific antigen and prostate volume in Korean men with benign prostatic hyperplasia: a multicentre study

OBJECTIVES

To evaluate the relationship between prostate specific antigen (PSA) and prostate volume (PV) in Korean men, as PV is a key predictor of both disease progression and response to medical therapy in patients with benign prostatic hyperplasia (BPH), and PSA has been suggested as a proxy marker to estimate the total PV, mainly in Caucasians.

PATIENTS AND METHODS

From 1999 to 2004, men aged 50-79 years with lower urinary tract symptoms (LUTS) and BPH were enrolled into this multicentre study. The analyses included 5716 patients presenting to 11 medical centres with LUTS (International Prostate Symptom Score >8, peak urinary flow rate <15 mL/s); they had a mean age of 64.3 years, mean baseline PV of 36.9 mL, and mean baseline PSA level of 2.2 ng/mL. Men with a baseline PSA of >10 ng/mL were excluded, to reduce the likelihood of including occult prostate cancer. A biopsy was taken in those with suspicious findings on a digital rectal examination or serum PSA level of >4 ng/mL, to exclude prostate cancer. Receiver operating characteristic (ROC) curves were constructed to evaluate the ability of serum PSA to predict threshold PV in men with BPH.

RESULTS

The PV and serum PSA level had an age-dependent log-linear relationship, the strength of which increased with age. The ROC curve analysis showed that PSA had good predictive value for various prostate volume thresholds (30, 40 and 50 mL).

CONCLUSIONS

The PSA-PV relationship in Korean men is similar to that in Caucasians, but Korean men have a slightly lower PSA level and a smaller PV than Caucasians. The approximate age-specific criteria for detecting Korean men with a PV of >40 mL were a PSA level of >1.3 ng/mL, >1.7 ng/mL and >2.0 ng/mL for men with BPH in their sixth, seventh and eighth decade, respectively.

The natural history of benign prostatic hyperplasia

The progression of benign prostatic hyperplasia (BPH) can be defined as a deterioration of clinical variables such as lower urinary tract symptoms (LUTS), health-related quality of life and peak flow rate, increased prostate size, or unfavourable outcomes such as acute urinary retention (AUR) and BPH-related surgery. The natural history of BPH is best analysed from longitudinal studies of community-dwelling men. In the Olmsted county study, which followed for 12 years a randomly selected cohort of 2115 men aged 40-79 years, there was an average increase in the International Prostate Symptom Score (IPSS) of 0.18 points per year, ranging from 0.05 for men in their fifties to 0.44 for those in their seventies. There was also a decrease in peak flow rate of 2% per year and a median prostate growth of 1.9% per year. The cumulative incidence of AUR was low (2.7% over 4 years). Information can also be collected from the placebo arms of controlled studies of men with symptomatic BPH, although the strict trial inclusion criteria and indeed the taking of a placebo itself introduce biases which limit the analysis of the natural history of the disease in this way, and its applicability to the general population. Hence, in the Medical Therapy of Prostatic Symptoms study, there is clear evidence that symptom deterioration, defined by a worsening of the IPSS of > or = 4 points, was by far the most prevalent progression event (79.5%), with a cumulative incidence of 14% over a mean follow-up of 4.5 years. As in the longitudinal community-based studies, AUR was rather uncommon (14.8% of overall progression events) with a cumulative incidence of 2%. BPH-related surgery, which was a secondary criterion in the study, was required in 5% of men. Similar conclusions can be drawn from a 2-year placebo-controlled study (ALTESS) assessing the impact of alfuzosin 10 mg once daily on LUTS/BPH progression in 1522 men with symptomatic BPH at high risk of developing AUR. Symptom deterioration was clearly the main progression event, with a cumulative incidence of 16.8%, compared to BPH-related surgery (6.5%) and AUR (2.2%). Thus, there is evidence from longitudinal studies, and to a lesser extent from the placebo arms of large controlled studies, that BPH is a progressive disease. Symptom worsening is by far the most frequently occurring progression event. Identifying those patients at risk of BPH progression is crucial to optimize their management.

Management of bladder, prostatic and pelvic floor disorders

Since its introduction in the late 1970s for the treatment of strabismus and blepharospasm, botulinum toxin (BoNT) has been increasingly used in the interventional treatment of several other disorders characterized by excessive or inappropriate muscle contractions. Over the years, the number of primary clinical publications has grown exponentially, and still continues to increase. It has been shown that BoNT blocks cholinergic nerve endings in the autonomic nervous system but does not block non-adrenergic non-cholinergic responses mediated by nitric oxide (NO). The present paper reviews a number of recent clinical indications for urological and pelvic floor dysfunctions, such as overactive and neurogenic bladder, non-bacterial prostatitis, benign prostatic hyperplasia, chronic anal fissure, or conditions associated to hyperactivity of the puborectalis muscle during straining. These indications provide a new promising palette of indications for future usage of BoNT in clinical practice.

Impact of medical treatments for benign prostatic hyperplasia on sexual function

Lower urinary tract symptoms (LUTS) and male sexual dysfunction are highly prevalent in ageing men, and are strongly linked. Various treatment strategies for benign prostatic hyperplasia (BPH)/LUTS may affect sexuality, with differences between drug classes and between drugs within a same class. The 5alpha-reductase inhibitors, finasteride and dutasteride, are associated with a greater risk of erectile dysfunction (ED), ejaculatory dysfunction (EjD) and decreased libido than is placebo. Alpha1-adrenoceptor blockers (alfuzosin, doxazosin, tamsulosin, terazosin) show an incidence of decreased libido and ED closely similar to placebo, but differ in their impact on ejaculation, tamsulosin being associated with a higher incidence of EjD (10%) than other alpha1-adrenoceptor blockers (0-1%) and placebo (1%), which is unrelated to retrograde ejaculation or higher efficacy. A randomized, placebo-controlled, cross-over study conducted in healthy volunteers showed that tamsulosin 0.8 mg once daily markedly decreased mean ejaculate volume in almost 90% of subjects, with 35% having no ejaculation. By contrast, there was no lack of ejaculation in subjects receiving alfuzosin 10 mg once daily or placebo. Sperm concentrations in urine after ejaculation were similar for the three treatment groups, confirming that the EjD with tamsulosin was unrelated to retrograde ejaculation. It may be related to a peripheral effect on seminal vesicles and/or the vas deferens. A central effect is also plausible, as tamsulosin shows a strong affinity for 5HT1A- and D2-like receptors, both of which are involved in the central command of ejaculation. In conclusion, because treatment options for managing BPH have different effects on sexuality, the sexual dimension should be considered when assessing patients' expectations and the choice of treatment.

Definition of at-risk patients: baseline variables

Benign prostatic hyperplasia (BPH) represents a significant burden in ageing men due to frequently associated lower urinary tract symptoms (LUTS), which may impair their quality of life. Some men will have progressive disease, mainly characterized by symptom deterioration of > or = 4 points on the International Prostate Symptom Score, but also by the occurrence of acute urinary retention (AUR) and BPH-related surgery. Identifying those at risk of unfavourable outcomes is important to optimize their management. Community-based longitudinal studies provide excellent data on the natural history of BPH. Baseline variables such as age, severe LUTS, low peak flow rate, high postvoid residual urine volume (PVR), enlarged prostate and high serum prostate-specific antigen (PSA) levels, have been identified as risk factors for AUR and BPH-related surgery in such studies. Placebo arms of controlled studies have more limited value for assessing the natural history, due to strong selection criteria which generate a regression to the mean artefact and narrow the applicability to the general population. Nevertheless, in these controlled studies, baseline serum PSA level and to a lesser extent prostate size consistently predicted the risk of AUR and BPH-related surgery. Conversely, quantitative variables such as baseline symptom severity and peak flow rate behaved paradoxically, probably as a consequence of strict inclusion criteria, resulting regression to the mean, and 'ceiling' effects. Results from the Medical Therapy of Prostatic Symptoms study and the Alfuzosin Long-Term Efficacy and Safety Study also suggest that using the PVR in clinical practice needs to be reconsidered as a predictor of BPH progression. Further research is needed to clarify the role of chronic inflammation in the process of BPH progression.

Benign prostatic hyperplasia: an insight into current investigational medical therapies

Benign prostatic hyperplasia (BPH) is a leading disorder of the elderly male population that is characterised by a progressive enlargement of prostatic tissue, resulting in obstruction of the proximal urethra and causing urinary flow disturbances. The pathophysiology of BPH associated with lower urinary tract symptoms is characterised by increased adrenergic tone (dynamic component) leading to smooth muscle contraction and prostatic overgrowth due to androgenic stimulation (static component); therefore, the therapeutic armamentarium of BPH can be broadly divided into antiadrenergic and antiandrogenic approaches. alpha1-Adrenoceptor antagonists and 5alpha-reductase inhibitors are well-established representatives of the two categories, respectively. Other antiandrogenic approaches involve gonadotropin-releasing hormone agonists and antagonists for the treatment of prostate hyperplasia. Apart from these approaches, new approaches with novel targets are emerging. The advent of new therapies is, however, more oriented towards the static component. These involve metabolic factors (hexokinase inhibitor), growth factors (vitamin D3 analogues), oxytocin antagonists and gonadotropin-releasing hormone Gi agonist-based therapies. Gene therapy and photodynamic therapies are other emerging therapies for relieving symptoms in BPH patients. With the initial success of upcoming targets, the unmet need to develop an efficacious and relatively safe therapeutic modality is discussed. Nevertheless, their long-term safety and efficacy needs to be evaluated in large-scale clinical trials. The future also belongs to combination therapies to combat both dynamic and static disease components and for extended indications such as micturition disorder and non-bacterial prostatitis.

Geographic variations in the use of medical and surgical therapies for benign prostatic hyperplasia

PURPOSE

Patients with BPH have several treatment options. Little is known about geographic variations in surgical rates for BPH and the market relationships to medical therapy, health resources and sociodemographic factors.

MATERIALS AND METHODS

We conducted a cross-sectional study using administrative data from 5 states in 2000. Rates of surgical and medical therapy were calculated per 100,000 men 55 years old or older. Main outcome measures were county level weighted coefficient of variation and systematic component of variation in therapy rates, as well as surgery rates as a function of medication dispensing rates, health care resources and sociodemographic characteristics.

RESULTS

North Carolina had the lowest surgery rates (26.3 minimally invasive procedures and 332.1 invasive surgeries per 100,000) and finasteride dispensing rates (503.5 per 100,000). Overall rates of medical therapy were 5 times higher than surgery rates. Geographic variations in surgical and medical therapy rates were significant for each state, and North Carolina had the greatest variation. An increase of 11.6 per 100,000 (95% CI, 6.5-55.8) in annual county level finasteride dispensing would be associated with a decrease in the surgery rate of 1 per 100,000, controlling for other variables.

CONCLUSIONS

There is significant systematic variation in rates of surgical and medical therapy for BPH at county and state levels. The relationship between finasteride and surgery in randomized clinical trials is generalizable to the marketplace. Finasteride rates are inversely related to surgery rates, and tamsulosin rates are positively associated with surgery rates. Surgery rates are not significantly associated with urologists per capita.

Dutasteride: a dual 5-alpha reductase inhibitor for the treatment of symptomatic benign prostatic hyperplasia

OBJECTIVE

To review the pharmacology, pharmacokinetics, efficacy, safety, drug interactions, and dosing recommendations of dutasteride, a 5-alpha reductase inhibitor for benign prostatic hyperplasia (BPH).

DATA SOURCES

A MEDLINE search (1966-February 2006) was conducted to extract human research data in the English language on dutasteride. Search terms included benign prostatic hyperplasia, dutasteride, and finasteride. The reference lists of articles identified through this search process, the manufacturer's Web site, and dutasteride prescribing information were also examined.

STUDY SELECTION AND DATA EXTRACTION

All published studies and clinical data from the manufacturer were included, with emphasis placed on randomized, controlled trials.

DATA SYNTHESIS

Dutasteride is approved for the treatment of symptomatic BPH in men with an enlarged prostate to improve urinary symptoms, reduce the risk of acute urinary retention, and reduce the need for BPH-related surgical interventions. Compared with placebo, dutasteride has been shown to significantly improve BPH symptoms, reduce the incidence of acute urinary retention and BPH-related surgery, and improve BPH-related quality of life. Few published data exist comparing dutasteride with finasteride. The most common adverse effects of dutasteride include ear, nose, and throat infection; malaise; headache; dizziness; and musculoskeletal pain.

CONCLUSIONS

Clinical trials, sponsored primarily by the manufacturer, have shown dutasteride to be an effective treatment of BPH compared with placebo and to likely possess efficacy similar to that of finasteride. Further studies are needed to gain a more clear understanding of any clinically significant differences between dutasteride and finasteride.

Combination therapy for the pharmacological management of benign prostatic hyperplasia: rationale and treatment options

The management of symptomatic benign prostatic hyperplasia (BPH) continues to evolve, with new techniques and forms of medical management being introduced and traditional surgical techniques being used less frequently. Medical management of BPH has evolved from nonspecific alpha-adrenoceptor antagonists to uroselective alpha-adrenoceptor antagonists and 5-alpha reductase inhibitors. Traditionally, alpha-adrenoceptor antagonists have been used for relief of lower urinary tract symptoms (LUTS) as a result of BPH and are known for their quick onset of action. 5-alpha Reductase inhibitors have proven useful for the prevention of BPH progression as measured by prostate volume, disease progression, incidence of acute urinary retention and the need for subsequent BPH-related surgery. Recent studies have shown that the combination of an alpha-adrenoceptor antagonist and a 5-alpha reductase inhibitor has significantly better efficacy than either drug alone or placebo. Currently, alpha-adrenoceptor antagonists are used in the acute setting or for short-term relief of LUTS. The combination of an alpha-adrenoceptor antagonist and a 5-alpha reductase inhibitor is used for the longer term management of BPH symptoms and to prevent progression of BPH and perhaps avoid surgical intervention.

Saw palmetto for benign prostatic hyperplasia

BACKGROUND

Saw palmetto is used by over 2 million men in the United States for the treatment of benign prostatic hyperplasia and is commonly recommended as an alternative to drugs approved by the Food and Drug Administration.

METHODS

In this double-blind trial, we randomly assigned 225 men over the age of 49 years who had moderate-to-severe symptoms of benign prostatic hyperplasia to one year of treatment with saw palmetto extract (160 mg twice a day) or placebo. The primary outcome measures were changes in the scores on the American Urological Association Symptom Index (AUASI) and the maximal urinary flow rate. Secondary outcome measures included changes in prostate size, residual urinary volume after voiding, quality of life, laboratory values, and the rate of reported adverse effects.

RESULTS

There was no significant difference between the saw palmetto and placebo groups in the change in AUASI scores (mean difference, 0.04 point; 95 percent confidence interval, -0.93 to 1.01), maximal urinary flow rate (mean difference, 0.43 ml per minute; 95 percent confidence interval, -0.52 to 1.38), prostate size, residual volume after voiding, quality of life, or serum prostate-specific antigen levels during the one-year study. The incidence of side effects was similar in the two groups.

CONCLUSIONS

In this study, saw palmetto did not improve symptoms or objective measures of benign prostatic hyperplasia. (ClinicalTrials.gov number, NCT00037154.).

Identification of the Major Oxidative 3α-Hydroxysteroid Dehydrogenase in Human Prostate That Converts 5α-Androstane-3α,17β-diol to 5α-Dihydrotestosterone: A Potential Therapeutic Target for Androgen-Dependent Disease

Androgen-dependent prostate diseases initially require 5α-dihydrotestosterone (DHT) for growth. The DHT product 5α-androstane-3α,17β-diol (3α-diol), is inactive at the androgen receptor (AR), but induces prostate growth, suggesting that an oxidative 3α-hydroxysteroid dehydrogenase (HSD) exists. Candidate enzymes that posses 3α-HSD activity are type 3 3α-HSD (AKR1C2), 11-cis retinol dehydrogenase (RODH 5), L-3-hydroxyacyl coenzyme A dehydrogenase , RODH like 3α-HSD (RL-HSD), novel type of human microsomal 3α-HSD, and retinol dehydrogenase 4 (RODH 4). In mammalian transfection studies all enzymes except AKR1C2 oxidized 3α-diol back to DHT where RODH 5, RODH 4, and RL-HSD were the most efficient. AKR1C2 catalyzed the reduction of DHT to 3α-diol, suggesting that its role is to eliminate DHT. Steady-state kinetic parameters indicated that RODH 4 and RL-HSD were high-affinity, low-capacity enzymes whereas RODH 5 was a low-affinity, high-capacity enzyme. AR-dependent reporter gene assays showed that RL-HSD, RODH 5, and RODH 4 shifted the dose-response curve for 3α-diol a 100-fold, yielding EC50 values of 2.5 × 10−9m, 1.5 × 10−9m, and 1.0 × 10−9m, respectively, when compared with the empty vector (EC50 = 1.9 × 10−7m). Real-time RT-PCR indicated that L-3-hydroxyacyl coenzyme A dehydrogenase and RL-HSD were expressed more than 15-fold higher compared with the other candidate oxidative enzymes in human prostate and that RL-HSD and AR were colocalized in primary prostate stromal cells. The data show that the major oxidative 3α-HSD in normal human prostate is RL-HSD and may be a new therapeutic target for treating prostate diseases.

Long-term therapy with the dual 5alpha-reductase inhibitor dutasteride is well tolerated in men with symptomatic benign prostatic hyperplasia

OBJECTIVE

To examine the long-term (4-year) safety and tolerability of dutasteride in the treatment of symptomatic benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Patients who completed the double-blind phase of three dutasteride Phase III studies were eligible to enter a 2-year open-label extension, during which all patients received dutasteride 0.5 mg. Safety was assessed, including adverse-event reporting, clinical laboratory assessments, yearly physical examinations, and vital sign assessments.

RESULTS

In all, 2340 patients entered the open-label phase, 1188 of whom previously received dutasteride during the double-blind phase of the study. The most common drug-related adverse events (occurring in > or = 1%) were effects on sexual function, which decreased with a longer duration of therapy. Gynaecomastia was reported in a small percentage of men throughout the 4-year study period. The incidence of individual sexual functional adverse events that led to withdrawal was < or = 1% (0.3-1.0%) during the 4-year study period. Dutasteride had no relevant effects on vital signs or clinical laboratory variables.

CONCLUSION

These data show that dutasteride is well tolerated during long-term use for the treatment of symptomatic BPH.

Development of nomogram to predict acute urinary retention or surgical intervention, with or without dutasteride therapy, in men with benign prostatic hyperplasia

OBJECTIVES

To develop a prediction model, or nomogram, that would predict the probability that a man with benign prostatic hyperplasia would experience acute urinary retention (AUR) or require surgical intervention (SI) within 2 years, with or without dutasteride therapy.

METHODS

We modeled 4294 men treated in the Phase III dutasteride benign prostatic hyperplasia trials. These men were characterized at baseline by a number of parameters, including the American Urological Association Symptom Index, Benign Prostatic Hyperplasia Impact Index questionnaire, prior use of selective alpha1-blockers, prostate volume, prostate-specific antigen level, and maximal flow rate. Cox proportional hazards regression analysis was used to relate these baseline variables to their future probability of AUR/SI within 2 years. The nomogram was internally validated with bootstrapping to assess its discrimination and calibration. Discrimination was quantified as the concordance index.

RESULTS

The nomogram appeared to be accurately calibrated and discriminating (concordance index 0.71, P <0.001).

CONCLUSIONS

We constructed a nomogram for predicting the probability that a man would experience AUR or require SI within 2 years of benign prostatic hyperplasia diagnosis. At 24 months of follow-up, 7.4% of placebo patients and 3.7% of dutasteride patients had experienced AUR and/or SI, representing a 50% relative risk reduction and a 3.7% absolute risk reduction. For the greatest risk patient randomized to the Phase III dutasteride trial, the nomogram predicted a maximal risk of 27%, significantly greater than the median risk of the placebo-treated patients.

Benign Prostatic Hypertrophy: A Progressive Pathology. Hypothesis for a Preventive Therapy

The purpose of this review is to enhance prevention as a new key aspect in the treatment of BPH. The concept of BPH as a progressive disease helps to adopt new approaches to patient evaluation and treatment. The disease progression, with respect to the risk of bladder function complications and alterations, to the progression of symptoms, and to the deterioration of the quality of life, leads to new ways of treating patients through a preventive as well as a symptomatic approach, thanks also to the identification of some parameters associated with the risk of BPH progression, i. e. the prostate volume and the serum PSA.

Furthermore, the concept of progression helps the clinician to identify different classes of BPH patients with different indications of medical treatment. The PLESS, ARIA and MTOPS multicentric studies point out the preventive potential of the therapy based on 5 alpha-reductase inhibitors (finasteride and dutasteride) or their combination with alpha-1 adrenergic blockers. Only a long term evaluation (4 years or more) can lead to the identification of statistically and clinically significant outcomes for the BPH preventive therapy.

The overlapping lower urinary tract symptoms of benign prostatic hyperplasia and prostatitis

PURPOSE OF REVIEW

To investigate the relationship, diagnosis and treatment of the overlapping lower urinary tract symptoms experienced by men diagnosed with benign prostatic hyperplasia and prostatitis.

RECENT FINDINGS

Recent studies have clearly shown that men can suffer from both benign prostatic hyperplasia and prostatitis. Approximately 5-20% of men diagnosed with benign prostatic hyperplasia suffer from prostatitis-like symptoms, while over one third of men diagnosed with benign prostatic hyperplasia have had a diagnosis of prostatitis in the past. Differentiation between these two symptom-based medical conditions can be difficult because of overlapping symptoms, but pain clearly identifies those patients with chronic prostatitis. Treatment for men with co-occurring benign prostatic hyperplasia and prostatitis may include alpha-blockers, 5alpha-reductase inhibitors and phytotherapies (saw palmetto and bee pollen extract), with evidence clearly showing the benefits of alpha-blocker therapy.

SUMMARY

Benign prostatic hyperplasia and chronic prostatitis are a common cause of lower urinary tract symptoms and frequently co-occur in older men. The best treatment for men with lower urinary tract symptoms associated with both benign prostatic hyperplasia and prostatitis is alpha-blockers.

To what extent do real life practice studies differ from randomized controlled trials in lower urinary tract symptoms/benign prostatic hyperplasia?

PURPOSE OF THE REVIEW

To compare the real-life practice studies and randomized controlled trials on benign prostatic hyperplasia in order to understand the applications of the data from the two types of study.

RECENT FINDINGS

Until recently, much of the available information on benign prostatic hyperplasia has come from randomized controlled trials conducted by secondary care urologists on selected populations of patients, who are likely to represent the more symptomatic among the cohort of men with lower urinary tract symptoms in the community. The strict inclusion criteria in these trials led to uncertainty about the applicability of the results to community populations. Moreover, as patients in randomized controlled trials are specially recruited, rather than being drawn from a general population of men with lower urinary tract symptoms, the calculations of incidence and prevalence rates may not be possible. In the last few years, there have been a few important real-life practice studies such as the Triumph project, the Quadraet study and the ALF-ONE study, which have provided very useful data regarding the incidence and prevalence of lower urinary tract symptoms/benign prostatic hyperplasia, the incidence of acute urinary retention, the impact of therapy on the risk of surgery related to benign prostatic hyperplasia and the predictors of disease progression during treatment with alpha-blocker.

SUMMARY

As the results from randomized controlled trials cannot always be generalized to daily urological practice, it is important to complement them with data made available by the real-life practice studies. In order to do that, the salient features in the methodology of both types of study must be understood.

BXL628, A Novel Vitamin D3 Analog Arrests Prostate Growth in Patients with Benign Prostatic Hyperplasia: A Randomized Clinical Trial

OBJECTIVE

To evaluate the effect of BXL628, a vitamin D3 analog, on prostate volume in patients with benign prostatic hyperplasia (BPH).

METHODS

We conducted a phase II, double blind, randomized, placebo controlled, clinical study. Patients eligible were aged>or=50 years, had a diagnosis of BPH and a prostate volume>or=40 ml. Eligible patients were randomized and given either BXL628 150 mcg daily or placebo for 12 weeks. All randomized patients underwent at baseline and at the end of study pelvic MRI to measure prostatic volume, uroflowmetry (Qmax), American Urological Association Symptom Index (AUASI), serum PSA, testosterone, dihydrotestosterone and luteizing hormone.

RESULTS

A total of 119 patients were randomized: 57 patients to BXL628 and 62 to placebo. The percentage change of prostate volume at 12 week was -2.90 in the BXL628 group vs. +4.32 in the placebo group (p-value<0.0001). The estimated difference between treatments (BXL628 minus placebo) was -7.22% (95% confidence limit -9.27 to -5.18). Considering Qmax, mean change vs. baseline was -0.30 in BXL628 vs. +1.50 in the placebo group: this finding was not statistically significant. The mean change of the AUASI total score at final visit vs. baseline was -1.77 in the BXL628 group vs. -3.45 in the placebo group (p=not significant).

CONCLUSION

BXL628 was able to arrest prostate growth within 12 weeks in men aged>or=50 years with prostatic volume>or=40 ml. Its unprecedented mechanism of action may offer a new opportunity for the treatment of BPH.

Alfuzosin for Symptomatic Benign Prostatic Hyperplasia: Long-Term Experience

PURPOSE

Evidence of the long-term efficacy and safety of alfuzosin treatment for LUTS indicative of BPH was examined.

MATERIALS AND METHODS

An English literature search of MEDLINE, PubMed and proceedings from scientific meetings from 1974 to 2004 was done. Search terms included benign prostatic hyperplasia, alfuzosin, treatment, alpha(1)-adrenergic receptor blocker, long-term, followup, lower urinary tract symptoms, complications or adverse events, sexual, retention and cardiovascular.

RESULTS

Currently alpha(1)-adrenergic receptor blocking agents are first line treatment for BPH. Although all alpha-blocking compounds show similar levels of efficacy for LUTS treatment, newer agents such as alfuzosin tend to demonstrate improved selectivity for the prostate and bladder with few vasodilatory effects and they have tolerability advantages over older alpha-blocking compounds. Immediate, sustained and newer extended release alfuzosin formulations significantly improve LUTS indicative of BPH but extended release alfuzosin may be more convenient to administer and it tends to show better vasodilatory tolerability than the older immediate release formulation.

CONCLUSIONS

When used to treat BPH, alfuzosin provides symptom relief, decreased residual post-void urine volume and a decreased risk of acute urinary retention, which are maintained during long-term use. Most vasodilatory side effects occur early in treatment and they become less frequent thereafter. Patient quality of life also improves with maximal improvements observed after 12 months of treatment. Continued study will further clarify the physiological, clinical and personal benefits produced by alfuzosin when used for the management of LUTS indicative of BPH.

Intake of selected micronutrients and the risk of surgically treated benign prostatic hyperplasia: a case-control study from Italy

OBJECTIVE

To analyze the relationship between surgically treated benign prostatic hyperplasia (BPH) and intake of selected micronutrients.

METHODS

A multicentric case-control study was conducted in Italy between 1991 and 2002. Cases were 1369 men with histologically confirmed, surgically treated BPH and controls were 1451 men younger than 75 yr, frequency matched by quinquennium of age and study center, admitted to the hospital for acute nonneoplastic diseases. Information was collected by trained interviewers using a structured validated food-frequency questionnaire. The odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by unconditional multiple logistic regression models.

RESULTS

The risk of BPH significantly decreased with increasing intake of carotene (OR=0.80 for an increment equal to the difference between the 80th and 20th percentile of intake), alpha-carotene (OR=0.83), beta-carotene (OR=0.82), and cis beta-carotene (OR=0.82) and tended to decrease with the intake of vitamin C (OR=0.89) and iron (OR=0.79). The OR tended to increase with the intake of sodium (OR=1.30) and zinc (OR=1.10). No systematic heterogeneity was observed across strata of age, education, and body mass index. No meaningful associations emerged for other antioxidants, such as folic acid, lycopene, lutein/zeaxanthin, vitamin E, vitamin D, nor for retinol.

CONCLUSIONS

Our results suggest a protective effect of carotene on the risk of BPH. The risk tended to decrease also with the intake of vitamin C and iron and tended to increase with the intake of sodium and zinc. Results also indicate that other antioxidants, including folic acid, lycopene, lutein/zeaxanthin, and vitamins D and E, and retinol were not related to the risk for this disease.

Risk factors for disease progression in patients with lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH): a systematic analysis of expert opinion

Disease progression has become an important issue for the management of lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH). Although several risk factors have been identified, no specific patient risk profiles have been established that can be useful in the day-to-day management of LUTS/BPH. In this study, an international panel of urologists developed a risk classification based on the attribution of a risk score to 243 unique patient profiles. From the perspective of clinical decision making, it was concluded that postvoid residual, symptom severity and maximum flow rate are the most relevant determinants of the risk of disease progression.

Prostate botulinum A toxin injection--an alternative treatment for benign prostatic obstruction in poor surgical candidates

OBJECTIVES

To evaluate, in a prospective study, the effectiveness of prostate injection of botulinum A toxin in patients who were poor surgical candidates. Patients with benign prostatic hyperplasia (BPH) are usually successfully treated with medical treatment or transurethral resection. However, some patients with chronic urinary retention or a large postvoid residual urine volume due to BPH are poor surgical candidates or are patients in whom medical treatment has failed.

METHODS

Ten patients with BPH and urinary retention or a large postvoid residual urine volume received 200 U botulinum A toxin injection into the transition zone of the prostate. The clinical results and urodynamic parameters at baseline and after treatment were compared.

RESULTS

All patients had an improvement in spontaneous voiding after treatment. Of them, 8 had an excellent result (80%) and 2 had an improved result. Both voiding pressure and postvoid residual volume were significantly decreased after treatment. The total prostate volume was significantly reduced, and the maximal flow rate was significantly increased after treatment. The maximal effects of botulinum A toxin appeared at about 1 week and were maintained at 3 and 6 months after treatment. At 6 to 12 months (mean 9) of follow-up, no patient had had recurrence of urinary retention and the voiding condition in all patients remained at the post-treatment status. No adverse effect was noted.

CONCLUSIONS

Prostate injection of botulinum A toxin is an effective alternative treatment with minimal adverse effects for patients with benign prostatic obstruction who are poor surgical candidates or in whom medical treatment has failed.

Managing patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

Many men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia can be managed safely and effectively by primary care providers. After a basic evaluation to exclude other diseases that may cause lower urinary tract symptoms, quantifying the degree of symptoms and bother, and perhaps making an assessment of prostate size, the primary care provider can determine which men require immediate evaluation by a urologist and which men may choose among various treatment options, including watchful waiting and various single agent or combination medication strategies. Recent information about risk factors for disease progression has also helped to inform patient decisions on which treatment option is best for the individual patient. The purpose of this review is to provide primary care providers with an approach to the management of men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia.

Monotherapy versus combination drug therapy for the treatment of benign prostatic hyperplasia

BACKGROUND

Benign prostatic hyperplasia (BPH) is a medical condition occurring in older men (ie, those aged >60 years) resulting from enlargement of the prostate gland. Consequently, affected men may experience bother-some urinary tract symptoms and diminished quality of life. The risk of lower urinary tract symptoms and complications such as acute urinary retention (AUR) may increase if BPH is untreated. Currently, 2 classes of drugs-alpha-adrenergic blockers (alpha-blockers) and 5alpha-reductase inhibitors-are indicated for the treatment of BPH. Although the 2 classes are commonly used in combination, the evidence has frequently not been supportive of this practice. Results from the Medical Therapy of Prostatic Symptoms (MTOPS) trial, the largest and longest clinical trial on this topic to date, revisited the role of combination therapy in the treatment of BPH.

OBJECTIVE

This review presents published trials evaluating alpha-blockers or 5alpha-reductase inhibitors used alone or in combination for the treatment of BPH.

METHODS

A MEDLINE search was conducted (December 1974 to November 2004) using the MeSH term prostatic hyperplasia limited to the subheading of drug therapy. These results were cross-referenced with the MeSH term combination drug therapy. An additional search was conducted using the MeSH terms finasteride and adrenergic alpha-antagonists limited to adverse effects and therapeutic uses. These results were cross-referenced with prostatic hyperplasia and combination drug therapy. Review articles and meta-analyses were also used.

RESULTS

The Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group and the Prospective European Doxazosin and Combination Therapy studies were well-designed trials that failed to support the theory that combination therapy is preferred over alpha-blockers alone. Finasteride was also shown to be no better than placebo for the outcomes of symptom score and peak urinary flow rates. Other trials suggested that combination therapy (which included finasteride) was more effective at reducing symptom scores in men with enlarged prostates at 1 year and that alpha-blockers may be successfully discontinued once patients are stabilized on finasteride. Although it was a prespecified secondary end point, the incidence of surgery or AUR was reduced by 51% using finasteride over placebo. The additive benefit finasteride provides in reducing symptoms, risk of AUR, and invasive surgery was observed within the first year of treatment and correlated with larger prostate sizes (mean [SD], approximately 55 [26] mL). The MTOPS trial further demonstrated a relative risk reduction of 66% in clinical progression rates for the combination-therapy group versus 39% for the doxazosin group compared with placebo (P < 0.001); the doxazosin group was not statistically different from the finasteride monotherapy group. Improvements in symptom scores were greater in the combination-therapy group versus the doxazosin (P = 0.006) and finasteride monotherapy (P < 0.001) groups.

CONCLUSION

Based on the literature, combination therapy has been proven to relieve symptoms and delay progression of BPH in men with moderate to severe symptoms and moderately enlarged prostate glands.

Use of joint models to assess treatment effects on disease markers and clinical events: the Proscar Long-Term Efficacy and Safety Study (PLESS)

Clinical trials often collect longitudinal measurements of a disease marker and time to a major clinical event of the disease to assess treatment effects. It makes sense to combine the treatment effects on both the longitudinal disease marker and the time to clinical event, especially when the clinical event is also mediated through the disease marker over time. In this paper we apply a joint modeling approach in the assessment of the treatment effects in treating benign prostatic hyperplasia (BPH) for the Proscar Long-Term Efficacy and Safety Study (PLESS).

Acute urinary retention in men: the risks and outcomes with medical therapy

This paper is restricted to the discussion of the relatively modern disorder of sudden painful inability to urinate in older men. It was not a common medical problem until the 19th century when, in developed countries, male life expectancy increased to beyond 60 years; it remains an uncommon problem in those developing countries where male life expectancy remains low, particularly in some sub-Saharan African countries where male life expectancy is only 44.8 years.

The impact of medical therapy on surgery for benign prostatic hyperplasia: a study comparing changes in a decade (1992-2002)

OBJECTIVES

To compare the clinical profile (age, comorbidities, symptom severity, and incidence of acute urinary retention, AUR), the type and duration of medical treatment, and indications for surgery of patients undergoing surgery for benign prostatic hyperplasia (BPH) in 1992 and 2002 at one centre.

PATIENTS AND METHODS

In this single-centre, retrospective, cross-sectional observational study, the medical history of all patients who had surgery for BPH in the first semester of 1992 (85) and 2002 (70) was reviewed. The preoperative clinical profile was determined by assessing age, main comorbidities, prostatic volume, maximum urinary flow rate and symptom severity. The type and duration of pharmacology for BPH was evaluated from the medical history and telephone contact with the patients. Indications for surgery, the method of operation and the weight of removed tissue (open adenectomy) or the volume of the resected tissue (transurethral resection) were obtained from the patients' records and compared. Surgical complications in both groups were assessed, as was the average stay in hospital.

RESULTS

In our institution, surgery for BPH decreased by 17.6% in the decade, with patients having surgery when older, at a mean (sd) of 69.1 (8.57) vs 72.3 (7.59) years, i.e. 3.1 years older (P = 0.028), but with similar comorbidities. Reasons for surgery in 1992/2002, respectively, were AUR in 41/37%, and symptoms worsening in 48/51%. The few cases of haematuria and bladder stone were similarly distributed in both groups. Pharmacology for BPH was prescribed in 46% of patients in 1992, phytotherapy being the most common (89%), whereas in 2002, 82% (P < 0.01) were treated, most of them with alpha-adrenergic antagonists (79%). Open surgery was indicated in 18.8% of patients in 1992 (mean adenoma weight 73.8 g, sd 37.12) and in 28.6% in 2002 (79.8 g, sd 35.41; P = 0.625). The mean (sd) hospital stay was 8.9 (4.06) vs 5.0 (1.22) days in 1992 and 2002, respectively (P < 0.01) for transurethral resection, and 14.1 (5.74) vs 8.7 (4.83) for open adenectomy (P = 0.013). The complication rate was similar for both groups.

CONCLUSIONS

Compared with 1992, fewer patients with BPH have surgery, when older and after receiving medical treatment for longer. The indications for surgery are similar. Significantly more patients had open surgery, perhaps because the progressive increase in prostate volume was not affected by the medical therapy used predominantly during this decade.

History of weight and obesity through life and risk of benign prostatic hyperplasia

OBJECTIVE

The relation of anthropometric measures, diabetes, hypertension and hyperlipidemia with benign prostatic hyperplasia (BPH) risk was investigated.

DESIGN

Hospital-based case-control study.

SUBJECTS

Cases were 1369 men with histologically confirmed BPH, and controls were 1451 men below 75 y, admitted to hospital for acute non-neoplastic diseases.

MEASUREMENTS

Using a structured questionnaire, trained interviewers collected information on self-reported height and weight, and measured waist and hip circumference of patients. The odds ratios (OR) and 95% confidence intervals (CI) were estimated using unconditional multiple logistic regression models.

RESULTS

Compared to the corresponding lowest quartile, the OR for the highest one were 0.76 (95% CI 0.59-0.98) for body weight, 0.71 (95% CI 0.54-0.94) for waist-to-hip ratio and 0.87 (95% CI 0.70-1.09) for body mass index (BMI, kg/m(2)). Compared to a lowest lifelong BMI <20.7 kg/m(2), the OR was 1.56 (95% CI 1.25-1.95) for a lowest lifelong BMI > or =23.7 kg/m(2). The OR was 0.74 (95% CI 0.60-0.93) for a lifelong increase of BMI > or =6.1 kg/m(2), compared to <1.6 kg/m(2). No association emerged for history of diabetes, hypertension and hyperlipidemia.

CONCLUSIONS

Overweight was modestly, inversely related to BPH. The hypothesis of reduced testosterone levels in obese individuals may explain the different BPH risk and need to be tested.