Incidence and prevalence of lower urinary tract symptoms suggestive of benign prostatic hyperplasia in primary care--the Triumph project

The predictive value of prostate cancer biomarkers depends on age and time to diagnosis: Towards a biologically-based screening strategy

Both benign and malignant prostate diseases elevate total prostate-specific antigen (tPSA), and the incidence of benign disease increases markedly with age. There is evidence, however, that free-to-total PSA ratio (%fPSA) and human kallikrein 2 (hK2) more closely reflect the malignant process. We tested the hypothesis that tPSA levels are more strongly predictive of cancer in younger when compared to older men, whereas %fPSA and hK2 are more strongly predictive in men tested closer to diagnosis. The study included 13,676 men age >/= 44 in Sweden, where PSA screening was uncommon during the study period. fPSA, tPSA and hK2 were measured in archived plasma collected during 1974-1986 in 501 men subsequently diagnosed with prostate cancer up to 1999 and in 1,292 matched controls. The predictive value of tPSA was lower in older men (p = 0.003) but was not strongly affected by time to diagnosis (p = 0.3); the predictive value of hK2 was higher closer to diagnosis (p < 0.0005) but was not modified by age (p = 0.7). A model including tPSA, fPSA and hK2 was superior (p = 0.02) to tPSA alone in older (AUC 0.819 vs. 0.794), but not in younger men (0.758 vs. 0.759). Total PSA can be used as a single marker at early middle age to predict long-term risk of prostate cancer and thus to determine intensity of subsequent screening. In contrast, %fPSA and hK2 add important predictive value in older men and much closer to diagnosis. Strategies for prostate cancer screening should be based on thorough understanding of the interaction of kallikrein-related biomarkers with prostate pathobiology.

Simple case definition of clinical benign prostatic hyperplasia, based on International Prostate Symptom Score, predicts general practitioner consultation rates

OBJECTIVES

To determine which case-definition of clinical benign prostatic hyperplasia (BPH) has the best predictive value for general practitioner visits for lower urinary tract symptoms (LUTS) suggestive of BPH. The incidence and prevalence rates of general practitioner visits for LUTS were also determined.

METHODS

A longitudinal, population-based study from 1995 to 2003 was conducted among 1688 men aged 50 to 78 years old. Data were collected on physical urologic parameters, quality of life, and symptom severity as determined from the International Prostate Symptom Score. Information on health-care-seeking behavior of all participants was collected from the general practitioner (GP) record using a computerized search engine and an additional manual check of the electronically selected files.

RESULTS

The incidence and prevalence rate of the men at risk was 19.6% and 14.0%, respectively, and these rates increased with age. For sensitivity and the positive predictive value, the case-definition of clinical BPH as an International Prostate Symptom Score greater than 7 had the best predictive value for GP visits for LUTS within 2 years after baseline.

CONCLUSIONS

Because only marginal improvement (greater specificity but lower sensitivity) in the prediction of GP visits for LUTS was possible by adding information on prostate volume and flow, for the prediction of future GP visits for LUTS suggestive of BPH, we suggest that the International Prostate Symptom Score questionnaire be used and that estimation of the prostate volume and flow is not required.

Characteristics of Patients Presenting with LUTS/BPH in Six European Countries

OBJECTIVES

Knowledge of the clinical profile of the population with lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH) is important for health care management, impacting on manpower requirements, pharmacologic demands and health service costs. Data collected by the TransEuropean Research Into the Use of Management Policies for LUTS suggestive of BPH in Primary Health care project were used to profile 4979 patients from six European countries newly presenting with LUTS/BPH to general practitioners or office-based urologists.

METHODS

At recruitment, the clinician completed a questionnaire detailing the treatment provided, examination results, and covariates including age, initial symptom severity and comorbidities. The patient completed an International Prostate Symptom Score/quality-of-life questionnaire.

RESULTS

The majority of patients (77%) sought medical advice because of the bothersomeness of their symptoms, and presented at ages between 58 and 71 years. Small but statistically significant differences among countries were found in initial symptom severity, initial quality of life and age at diagnosis, but these are not thought to be clinically significant. There were marked national differences in patient management, with, for example, 10% of patients in France reporting no examinations, compared with 0.5% in Poland, while free-flow measurements varied from less than 1% in France to 35% in Poland.

CONCLUSIONS

Patient heterogeneity does not explain the differences in patient management among countries, which undoubtedly is the result of differences in health care traditions, infrastructure and socioeconomic factors, as well as patient preference.

Systematic review and meta-analysis of Transurethral Needle Ablation in symptomatic Benign Prostatic Hyperplasia

BACKGROUND

Benign prostatic hyperplasia (BPH) constitutes a major clinical problem. Minimally invasive therapies for the treatment of symptomatic BPH include Transurethral Needle Ablation (TUNA), but it is unclear what impact this technique has on the disease and its role among other currently available therapeutic options. The objective of this study is to ascertain the efficacy and safety of TUNA in the treatment of BPH.

METHODS

Systematic review of the literature until January 2005 and meta-analysis of clinical studies assessing TUNA in symptomatic BPH. Studies were critically appraised. Estimates of effect were calculated according to the random-effects model.

RESULTS

35 studies (9 comparative, 26 non-comparative) were included. Although evidence was limited by methodological issues, the analysis of relevant outcomes indicates that while TUNA significantly improves BPH parameters with respect to baseline, it does not reach the same level of efficacy as TURP in respect to all subjective and objective variables. Further, its efficacy declines in the long-term with a rate of secondary-treatment significantly higher than of TURP [OR: 7.44 (2.47, 22.43)]. Conversely, TUNA seems to be a relatively safe technique and shows a lower rate of complications than TURP [OR:0.14 (0.05, 0.14)] with differences being particularly noteworthy in terms of postoperative bleeding and sexual disorders. Likewise, TUNA has fewer anesthetic requirements and generates a shorter hospital stay than TURP [WMD: -1.9 days (-2.75, -1.05)]. Scarce data and lack of replication of comparisons hinder the assessment of TUNA vs. other local therapies. No comparisons with medical treatment were found.

CONCLUSION

The body of evidence on which TUNA has been introduced into clinical practice is of only moderate-low quality. Available evidence suggest that TUNA is a relatively effective and safe technique that may eventually prove to have a role in selected patients with symptomatic BPH. TUNA significantly improves BPH parameters with respect to baseline values, but it does not reach the same level of efficacy and long-lasting success as TURP. On the other hand, TUNA seems to be superior to TURP in terms of associated morbidity, anesthetic requirements and length of hospital stay. With respect to the role of TUNA vis-à-vis other minimally invasive therapies, the results of this review indicate that there are insufficient data to define this with any degree of accuracy. Overall cost-effectiveness and the role of TUNA versus medical treatment need further evaluation.

Transurethral microwave thermotherapy for the treatment of BPH: still a challenger?

Minimally invasive therapies for treatment of benign prostatic hyperplasia (BPH) compete with the gold standard transurethral resection of the prostate (TURP). Comparisons of efficacy and safety have broadened the knowledge of different treatment modalities. Concerns of quality of life such as unaltered sexual function as well as cost considerations drive the market to develop techniques of lower level invasiveness. Among the competitors the office based transurethral microwave thermotherapy (TUMT) provides the broadest scale of scientific data. Numerous manufacturers sell various modifications of this technology. According to different clinical studies TUMT proved to be an effective, safe, and durable therapy for the treatment of lower urinary tract symptoms (LUTS) secondary to BPH. However, TURP still holds the steadier long-term results and is more effective to reduce obstruction as well as other LUTS.

Predictive factors for nocturia in elderly men: a cross-sectional study in 21 general practices

OBJECTIVE

To measure the prevalence of nocturia in general practice and to determine which factors are associated with nocturia.

SUBJECTS AND METHODS

Data were collected from 3048 elderly men, who completed a questionnaire that was sent to every man aged 55-75 years in 21 general practices in Maastricht (the Netherlands). The symptom of nocturia was defined as two or more nocturnal voids. We investigated the prevalence of nocturia and the predictive relationships with the following factors: cerebrovascular disease, diabetes mellitus/insipidus (DMI), Parkinson's diseases, cardiovascular disease, hypertension, bladder/prostate cancer, kidney diseases, urinary bladder inflammation, congenital diseases (kidneys or prostate), using medical treatment for lower urinary tract symptoms, other treatment, psychological depression, symptoms suggestive of benign prostatic hyperplasia (BPH), and alcohol intake.

RESULTS

Data from 2934 respondents were analysed; the prevalence of nocturia (two or more nocturnal voids) was 32.9% (965 men). The frequency of the number of nocturnal voids was: zero in 588 (20.0%), one in 1344 (45.8%), two in 611 (20.8%), three in 208 (7.1%), four in 70 (2.4%), and five or more in 76 (2.6%), with 37 values missing. A multivariate logistic regression analysis showed that nocturia in elderly men was significantly related to bladder/prostate cancer, cerebrovascular disease, treatment of voiding disorders, and moderate alcohol consumption. Next to these, BPH had a significant relationship with nocturia, especially in respondents with DMI and hypertension. Cardiovascular disease or hypertension was significantly related to nocturia, mutually replacing each other as a risk factor.

CONCLUSION

Nocturia in elderly men is be related to many sources of potential risk factors: earlier urological diseases, cardiovascular and cerebrovascular diseases, BPH, DMI and behavioural habits. Some of these sources may interact and generate especially high risk in some groups for nocturia.

Risk Factors for Benign Prostatic Hyperplasia in South Korean Men

OBJECTIVES

Benign prostatic hyperplasia (BPH) is the most common prostate disease in middle-aged and elderly men, and leads to severe impairment in later life. Despite the significant effect on public health, the causes of BPH have received little attention. Identifying risk factors for BPH is crucial for understanding the etiology and for determining effective interventions or targeting strategies.

METHODS

This survey was performed in two steps: (1) a pilot study was first conducted prior to the main study in order to estimate baseline characteristics, and (2) the main study investigated the prevalence and risk factors of BPH using clinical diagnostic tests and a questionnaire. A total of 641 males, aged 50-79 years, participated in this community-based cross-sectional study.

RESULTS

Age was the only significant demographic risk factor of BPH. The presence of chronic bronchitis and a high prostate-specific antigen (PSA) level increased the risk by three- and twofold, respectively. The risk decreased as drinking frequency increased. Physical activity 3-5 times/week reduced the risk relative to being active less than twice per week; however, engaging in physical activity nearly everyday increased the risk 1.7-fold relative to being active up to twice per week.

CONCLUSIONS

Although BPH has been considered a disease that is unavoidable with advancing age, the clear identification and control of the underlying risk factors might allow effective prevention by placing a special emphasis on those at risk.

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.

CXCL12 overexpression and secretion by aging fibroblasts enhance human prostate epithelial proliferation in vitro

The direct relationship between the aging process and the incidence and prevalence of both benign prostatic hyperplasia (BPH) and prostate cancer (PCa) implies that certain risk factors associated with the development of both diseases increase with the aging process. In particular, both diseases share an overly proliferative phenotype, suggesting that mechanisms that normally act to suppress cellular proliferation are disrupted or rendered dysfunctional as a consequence of the aging process. We propose that one such mechanism involves changes in the prostate microenvironment, which 'evolves' during the aging process and disrupts paracrine interactions between epithelial and associated stromal fibroblasts. We show that stromal fibroblasts isolated from the prostates of men 63-81 years of age at the time of surgery express and secrete higher levels of the CXCL12 chemokine compared with those isolated from younger men, and stimulate CXCR4-mediated signaling pathways that induce cellular proliferation. These studies represent an important first step towards a mechanistic elucidation of the role of aging in the etiology of benign and malignant prostatic diseases.

Medical consumption and costs during a one-year follow-up of patients with LUTS suggestive of BPH in six european countries: report of the TRIUMPH study

OBJECTIVE

To determine the medical consumption and associated treatment costs of patients with LUTS suggestive of BPH.

METHODS

A prospective, cross-sectional, observational survey in six European countries: France, Germany, Italy, Poland, Spain and the United Kingdom, with a one-year follow-up of incident and prevalent patients.

RESULTS

Treatment costs were estimated for 5,057 patients with a mean age of 66 years and a mean IPSS score at inclusion of 11.5. In 30% of patients watchful waiting was the therapy of choice for the full follow-up period, 57% were prescribed alpha-lockers, 11% finasteride and 10% phytotherapy at any moment during the follow-up (including switches and combination of treatment). Surgery rate was 4.9%. Mean one-year treatment costs were 858 per patient, three quarters of which concerned medication costs. Multivariate regression analysis showed that medication choice, complications and undergoing surgery were associated with higher costs.

CONCLUSIONS

Treatment costs for patients with LUTS suggestive of BPH were moderate and largely consisted of medication costs. Daily practice and associated costs varied considerably across the six countries.

The prevalence and correlates of urinary tract symptoms in Norwegian men: the HUNT study

OBJECTIVES

To estimate the prevalence of lower urinary tract symptoms (LUTS) by severity (using the International Prostate Symptom Score, IPSS) in a population-based study of men aged > or = 20 years, and to assess the association between putative risk factors and the presence of moderate to severe LUTS.

SUBJECTS AND METHODS

Between 1995 and 1997, LUTS data were collected from 21 694 male residents aged > or = 20 years in Nord Trøndelag County in Norway, using the IPSS; from the IPSS (score 0-35) LUTS was defined as a score of > or = 8, indicating moderate to severe symptoms. We estimated the prevalence of LUTS and used logistic regression analysis to study lifestyle and anthropometric factors, and comorbidity related to LUTS.

RESULTS

The overall prevalence of moderate to severe LUTS was 15.8% (13.2% moderate and 2.6% severe). The prevalence of LUTS increased strongly with age, from approximately 5% among men aged < 40 years to > 30% when aged > or = 70 years. Factors positively associated with an increased risk of moderate and severe LUTS were anthropometric (body mass index and waist hip ratio) and lifestyle factors (alcohol consumption and smoking), as well as comorbid conditions, including diabetes, history of stroke, muscle complaints and osteoarthritis.

CONCLUSION

The findings from this population-based study suggest that the prevalence of LUTS among men aged > or = 20 years may be lower than previously estimated. Although LUTS may be viewed as an inevitable consequence of ageing, it appears to be exacerbated by lifestyle factors and comorbid conditions.

Selecting therapy for maintaining sexual function in patients with benign prostatic hyperplasia

In the first of these mini-reviews the selection of therapy for the maintenance of sexual function in patients with BPH is outlined, along with an explanation of how altered regulation of neurotransmitters, especially noradrenaline, may underlie the syndrome of LUTS and sexual dysfunction. Other mini-reviews outline the current status of robotic surgery to treat renal and adrenal disorders, and its future applications, and the potential use of the nitric oxide/cGMP pathway as a potential target to treat BOO associated with benign prostatic enlargement. Finally, the capacity to be creative in academic departments is extolled as a core property of academicians, and its surfacing described as having the potential to revitalize individuals and departments.

Treatment of Benign Prostatic Hyperplasia and Occurrence of Prostatic Surgery and Acute Urinary Retention: A Population-Based Cohort Study in The Netherlands

OBJECTIVES

To assess and compare the risk of prostatic surgery in (subsets of) patients with a diagnosis of BPH. We sought to expand on data of an earlier pharmacy-based study by obtaining more information on BPH disease parameters by using a Dutch GP-based research database.

METHODS

A retrospective cohort study (1994-mid-year 2002) was conducted among 1430 men aged > or =45 years with > or =6 months of registration with the GP. BPH case identification was based on review of medical records.

RESULTS

Overall, we found that there was no difference in the risk of prostatic surgery between patients on medical treatment and watchful waiting. Patients using 5alpha-reductase inhibitors (5-ARIs) at any stage had a statistically significant reduced risk of surgery compared to patients using alpha-blockers only: adjusted hazard ratio 0.35 (95%CI: 0.13-0.96). The routine collection of BPH parameters were insufficient to be useful in the analysis.

CONCLUSION

Patients using 5-ARIs seemed to have a reduced risk of prostatic surgery compared to patients using alpha-blockers. However, it was unknown whether the disease profile of 5-ARI users is different compare to non-5-ARI-treated and untreated patients with BPH, as detailed medical information necessary to characterise patients according to the BPH disease severity and development of disease parameters is not routinely recorded by GPs.

Low Incidence of Acute Urinary Retention in the General Male Population: The Triumph Project

OBJECTIVE

To describe the incidence of acute urinary retention (AUR) in the general male population and in a population of men newly diagnosed with lower urinary tract symptoms suggestive of BPH (LUTS/BPH).

METHODS

We performed a retrospective cohort study in the Integrated Primary Care Information (IPCI) database, a GP research database in The Netherlands, during the period 1995-2000. All males, > or =45 years, without a history of AUR or radical cystectomy were included in the study. In addition, we followed a sub-cohort of men, newly diagnosed with LUTS/BPH. AUR was defined as the sudden inability to urinate, requiring catheterization.

RESULTS

Amongst 56,958 males with a mean follow-up of 2.8 years, 344 AUR cases occurred (incidence rate 2.2/1000 man-years) of whom more than 40% were precipitated. AUR was the first symptom of LUTS/BPH in 73 (49%) of the 149 AUR cases that occurred in men newly diagnosed with LUTS/BPH. The risk of AUR was 11-fold higher in patients newly diagnosed with LUTS/BPH (RR 11.5; 95%CI: 8.4-15.6) with an overall incidence rate of 18.3/1000 man-years (95%CI: 14.5-22.8).

CONCLUSIONS

The incidence rate of AUR is low in the general population but substantial in a population of men newly diagnosed with LUTS/BPH. The incidence rate increases with age and AUR is precipitated in approximately 40% of all cases. Within the LUTS/BPH cohort, AUR is the first presenting symptom of BPH in 50% of all AUR cases.

Effects of a shared protocol between urologists and general practitioners on referral patterns and initial diagnostic management of men with lower urinary tract symptoms in Italy: the Prostate Destination study

OBJECTIVE

To assess whether adopting a shared protocol between urologists and general practitioners (GPs) might change diagnostic procedures and referral patterns in the management of men with lower urinary tract symptoms (LUTS).

SUBJECTS AND METHODS

Forty-five urological centres and 263 GPs in Italy participated in this prospective study. Procedures adopted by GPs for evaluating five consecutive patients (aged > or = 50 years) were compared before (phase 1) and after (phase 2) implementation of the shared protocol. An evidence-based diagnostic algorithm was developed and approved by participating urologists and presented to local GPs at a training session. Protocol modifications were allowed after discussion with GPs. Direct costs of diagnostic procedures carried out before and after implementing the protocol were calculated from the perspective of the national health service.

RESULTS

In all, 903 patients were evaluable in phase 1 and 856 in phase 2. Implementation of the protocol did not change referral patterns, with about half the patients being managed entirely by GPs. The use of a digital rectal examination by GPs increased from 32% to 41%, use of transrectal and suprapubic ultrasonography decreased from 33% to 23% and 53% to 44%, respectively, (all P < 0.001) and use of the International Prostate Symptom Score increased from 4.5% to 23.1% (P < 0.001). Overall, protocol-recommended tests were used more frequently, while those not recommended decreased after implementing the protocol. However, overuse of the tests not recommended (i.e. urine culture and free/total prostate specific antigen ratio) remained high. The mean cost per patient of diagnostic procedures ordered by GPs decreased from Euros 71.82 to Euros 61.93, with Euros 9.9 saved for each patient.

CONCLUSION

Our intervention failed to decrease the percentage of cases of LUTS being referred to specialists, but was moderately effective in inducing changes in the diagnostic management by GPs that were indicative of increased compliance with best-practice principles, and produced cost savings of 13.8%.

Development and validation of a quality-of-life scale for Chinese patients with benign prostatic hyperplasia

OBJECTIVE

To develop and validate a quality of life (QoL) scale for Chinese patients with benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

According to the QoL definition of the World Health Organisation, we adhered to the rigorous guidelines of instrument development to form a pool of items, selected items and validated the scale, using data from 256 patients with BPH.

RESULTS

A 74-item QoL scale for BPH (prior test version; BPH-QLS), including five domains (disease, physical, social, psychological, satisfaction) was developed and had good reliability and validity. The test-retest correlation coefficient and Cronbach's alpha coefficient of the BPH-QLS were 0.892 and 0.966. Thirteen common factors were extracted according to the conceptual model. The correlations of the BPH-QLS with the Short Form-36, the International Prostate Symptom Score (IPSS), and IPSS QoL score, and a published BPH-specific QoL scale were 0.784, 0.493, 0.462 and 0.762, respectively. The BPH-QLS could be used to discriminate among patients with a different QoL.

CONCLUSION

The new scale is reliable, valid and sensitive, and we recommend using the BPH-QLS in Chinese and Chinese-born patients worldwide to assist in clinical practice.

Long-term treatment outcomes of CoreTherm microwave feedback thermotherapy

The gold standard for definitive management of symptomatic benign prostatic hypertrophy is transurethral resection of the prostate (TURP). Despite its efficacy, TURP has significant morbidity/mortality concerns such as hemorrhage and transurethral resection syndrome. This is especially worrisome for the medically high-risk patient, but the high rates of retrograde ejaculation found with TURP also pose a problem for young patients. A minimally invasive, outpatient alternative to TURP that has long-term efficacy, low morbidity/mortality, and provides a cost-effective advantage is in high demand. This review article discusses microwave thermotherapy as such an option and reports the long-term experience with the CoreTherm (CoreTherm Operations AB, Sweden) device.

A case-based evaluation of SRD5A1, SRD5A2, AR, and ADRA1A as candidate genes for severity of BPH

In men with a clinical diagnosis of benign prostatic hyperplasia (BPH), polytomous logistic regression analysis was conducted to evaluate associations between two silent polymorphisms in SRD5A1 (codon positions 30 and 116), two polymorphisms in SRD5A2 (Val89Leu substitution and C to T transition in intron 1), a trinucleotide (CAG)n repeat in androgen receptor (AR), and an Arg492Cys substitution in ADRA1A and clinical parameters that characterize severity of BPH. Candidate gene selection was based on two mechanistic pathways targeted by pharmacotherapy for BPH: (1) androgen metabolic loci contributing to prostate growth (static obstruction); and (2) factors affecting smooth muscle tone (dynamic obstruction). Polymorphisms in SRD5A2 were not associated with severity of BPH; however, SRD5A1 polymorphisms were associated with severity of BPH. The process(es) in which these silent single-nucleotide polymorphisms (SNPs) influence BPH phenotypes is unknown and additional studies will be needed to assess whether these SNPs have direct functional consequences. The characterization of additional molecular factors that contribute to static and dynamic obstruction may help predict response to pharmacotherapy and serve to identify novel drug targets for the clinical management of BPH.

Real life practice in the management of benign prostatic hyperplasia

PURPOSE OF REVIEW

To review the current diagnostic and treatment options of lower urinary tract symptom due to benign prostatic hyperplasia and to put data from real life practice into perspective.

RECENT FINDINGS

The overall incidence rate of lower urinary tract symptom/benign prostatic hyperplasia was found at 15 per 1000 man-years (95% CI 14.8-16.1). The incidence increases with age from 3/1000 man-years at 45-49 years to 38/1000 man-years at 75-79 years. Recent diagnostic studies include the use of PSA to estimate prostate volume and its predictive value for the long-term risk of prostate enlargement. Variability of the International Prostate Symptom Score when filled at home and in the hospital is discussed. The first-line treatment option remains medical therapy. The most prescribed alpha-blockers are terazosin, alfuzosin, and tamsulosin, which are comparable in efficacy. The efficacy of finasteride is also confirmed, especially for enlarged prostates with the possibility of volume reduction up to 30%. Interventional therapy begins when there is evidence of moderate to severe symptoms. Long term results put transurethral microwave thermotherapy in advantage over other minimally invasive modalities. Surgical treatment remains the procedure with the best results. Open prostatectomy is still indicated for severely enlarged prostates. Transurethral resection for medium-sized prostates and bladder-neck incision for small prostates also remain the best option.

SUMMARY

Real life practice studies in the last few years have broadened our insight into the application of different diagnostic and treatment modalities. Since results from randomized controlled trials can not always be extrapolated to daily urological practice, real life practice studies made data available to complement data from randomized controlled trials.

A rational approach to benign prostatic hyperplasia evaluation: recent advances

PURPOSE OF REVIEW

In this article we aim to outline the recent advances in the evaluation of a patient with symptoms suggestive of benign prostatic hyperplasia. We define the role of the clinical evaluation and techniques that are evolving for the appropriate management of a patient with benign prostatic hyperplasia. Both non-invasive and invasive investigation techniques are reviewed.

RECENT FINDINGS

Initiating early and appropriate treatment is the primary aim of investigation for a patient with lower urinary tract symptoms. Both clinical history and examination and appropriate investigations are vital to establishing a diagnosis. Symptom scores, prostate specific antigen and prostate volume were found to closely relate in predicting the progression of benign prostatic hyperplasia and in recent years increased interest has centred on the progression of this disease principally related to the development of new pharmacotherapy. Despite these positive findings further research is needed to develop reliable tools to predict progression. Newer ultrasound techniques hold promise for the future. Conventional pressure flow studies have a defined role in excluding patients who are less likely to benefit from prostatic surgery by providing information on detrusor function; and non-invasive urodynamic techniques need further evaluation but appear to be promising.

SUMMARY

The minimal initial evaluation of a patient with benign prostatic hyperplasia should include a thorough history, digital rectal and neurological examinations, symptom scoring (including quality of life and sexual score) and measurement of serum prostate specific antigen. Other methods should be reserved for more complex situations. Attempts should be made at identifying those patients in whom the disease process is likely to progress.

Treatment Strategies, Patterns of Drug Use and Treatment Discontinuation in Men with LUTS Suggestive of Benign Prostatic Hyperplasia: The Triumph Project

OBJECTIVES

We aimed to describe treatment strategies for lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH), adherence to and persistence with pharmacological treatment and the association between the type of LUTS/BPH complaints and early treatment discontinuation.

METHODS

Within a large GP database (IPCI) in the Netherlands we identified all males > or =45 years newly diagnosed with LUTS/BPH during 1995-2000. Details on treatment were assessed from the electronic patient records. Logistic regression analysis was used to estimate the association between the type of main urinary complaints and early treatment discontinuation.

RESULTS

Of the 2214 men with incident LUTS/BPH, 1075 received pharmacological treatment and 238 underwent prostate surgery. The average adherence differed slightly between drugs: 67% for alpha-blockers, 73% for 5alpha-reductase inhibitors and 71% for combination therapy. 26% of the treated patients discontinued treatment early. The probability of early discontinuation was higher if patients mainly expressed one type of complaint: voiding (OR(adj) 3.38; 95%CI: 1.89-6.04), post micturition (OR(adj) 2.37; 95%CI: 1.15-4.87) or storage symptoms (OR(adj) 1.85; 95%CI: 1.16-2.95) as compared to patients expressing a combination of symptoms. The risk of early discontinuation was higher if patients had a normal PSA measurement. Older age and a higher chronic disease score protected against early treatment discontinuation.

CONCLUSIONS

Almost half of newly diagnosed LUTS/BPH patients are pharmacologically treated, and a quarter discontinues very rapidly. Stopping early is more frequent among younger persons, persons with only one type of main urinary complaint, no other co-morbidity and a normal PSA.