Natural history and epidemiology of benign prostatic hyperplasia

Awareness and prevalence of self-reported benign prostatic hyperplasia: a cross-sectional study in Saudi Arabia

Background

Benign prostatic hyperplasia (BPH) is a prevalent condition in older men, causing significant morbidity. Despite recent progress, essential concerns of the disease remain under-researched. This study aims to assess knowledge and estimate self-reported prevalence of BPH in Saudi Arabian men. Understanding BPH prevalence in Saudi Arabia is essential for healthcare planning, resource allocation, public awareness, early detection, intervention, research, and addressing regional variations.

Method

A cross-sectional study was conducted from February to May 2022 using a validated questionnaire. Univariate and multivariate statistical methods assessed knowledge of BPH among 559 adult Saudi men (mean age: 47.2 years) and its association with demographic variables.

Results

The self-reported prevalence rate of BPH for Saudi Arabian men was 12.0%. Most adults (74.2%) were aware that BPH is a risk factor for prostate cancer and 75% were aware of the increased risk of BPH in older people. Furthermore, 44.5% of participants associated nocturia with BPH, while 76.6% related urinary tract infection (UTI) with BPH. The study demonstrated a significant association between BPH awareness and marital status (p = 0.02), level of education (p = 0.02), and employment status (p = 0.04).

Conclusion

While men in Saudi Arabia generally had sufficient knowledge about BPH, there was a knowledge gap regarding certain risk factors like obesity and cardiac diseases. To address this, an educational program should be developed for both the general population and those at high risk of BPH.

Tumor necrosis factor-alpha, transforming growth factor-beta, degree of lower urinary tract symptoms as predictors of erectile dysfunction in benign prostatic hyperplasia patients

Objective

Erectile dysfunction (ED) is a condition of insufficient penile erection, consistently or recurrently, for sexual activity. Tumor necrosis factor-alpha (TNF-α) induces transforming growth factor-beta (TGF-β), which causes the transition of epithelial cells into mesenchymal cells that affect ED. This study aimed to evaluate the roles of TNF-α, TGF-β, degree of lower urinary tract symptoms, and prostatic volume for the presence of ED in benign prostatic hyperplasia (BPH) patients.

Methods

Our study performed an analytic observational retrospective cohort study using secondary data from four hospitals in Bali, Indonesia, including medical records and other administrative data. The sample was BPH patients with several history qualifications.

Results

Our sample was 83 respondents, ranging from 50 years to 80 years, 61 respondents with ED and 22 with non-ED. The International Prostate Symptom Score showed a significant result, which indicates that ED is more common in patients with higher International Prostate Symptom Score (p=0.002). Moreover, the TNF-α of ≥43.9 pg/mg and TGF-β of ≥175.8 pg/mL were significantly associated with the presence of ED in BPH patients (p<0.0001). Despite these results, prostate volume is not significant with ED (p=0.947).

Conclusion

TNF-α, TGF-β, and lower urinary tract symptoms severity can predict the occurrence of ED in BPH, while prostatic volume was not significant.

A guide to diagnosing and treating benign prostatic hypertrophy

Benign prostatic hypertrophy (BPH) is a condition where the prostate becomes enlarged. It affects all men and is part of the ageing process. Globally, the incidence rates of BPH have risen by 70% between 2000-2019. When left untreated, it can lead to acute urinary retention, impaired bladder emptying, urinary tract infections, bladder stones, kidney failure or gross haematuria. In this article, Linda Nazarko describes the causes and consequences of BPH along with treatment options that are available for it.

5-alpha reductase inhibitors and MRI prostates: actively reducing prostate sizes and ambiguity

BACKGROUND

Magnetic resonance imaging (MRI) scans are increasingly first-line investigations for suspected prostate cancer, and essential in the decision for biopsy. 5-alpha reductase inhibitor (5-ARI) use has been shown to reduce prostate size and prostate cancer risk. However, insufficient data exists on how 5-ARI use affects MRI findings and yield of biopsy. This study explores the differences in imaging and prostate cancer diagnoses between patients receiving and not receiving 5-ARI therapy.

METHODS

From 2015 to 2020, we collected retrospective data of consecutive patients undergoing prostate biopsy at one centre. We included patients who were biopsy-naïve, had prior negative biopsies, or on active surveillance for low-grade prostate cancer. Clinical and pathological data was collected, including 5-ARI use, Prostate Imaging Reporting and Data System (PIRADS) classification and biopsy results.

RESULTS

351 men underwent saturation biopsy with or without targeted biopsies. 54 (15.3%) had a history of 5-ARI use. On mpMRI, there was no significant difference between the 5ARI and non-5-ARI groups in PIRADS distribution, number of lesions, and lesion location. Significantly fewer cancers were detected in the 5-ARI group (46.3% vs. 68.0%; p < 0.01). There were no significant differences in PIRADS distribution in 5-ARI patients with positive and negative biopsy.

CONCLUSION

Our study found significant differences in biochemical, imaging and biopsy characteristics between 5-ARI and non-5-ARI groups. While both groups had similar PIRADS distribution, 5-ARI patients had a lower rate of positive biopsies across all PIRADS categories, which may suggest that the use of 5ARI may confound MRI findings. Further studies on how 5-ARI therapy affects the imaging characteristics of prostate cancer should be performed.

Benign prostatic hyperplasia and cardiovascular risk: a prospective study among Chinese men

PURPOSE

To examine the prospective association of BPH with subsequent risk of CVD, including heart disease and stroke.

METHODS

We used data from China Health and Retirement Longitudinal Study of 5242 Chinese men aged 45 years or older. During a follow-up of 7 years, we identified 613 cases of non-fatal CVD, including 417 heart diseases and 254 strokes. Cox proportional hazards models yielded hazard ratios (HRs) relating BPH to CVD, heart disease, and stroke incidence.

RESULTS

Overall, 8.1% of men reported a history of BPH diagnosed by physicians at baseline. As compared with men without a history of BPH, those reporting a history of BPH had an increased risk of developing CVD (multivariable-adjusted HR = 1.43 [1.12, 1.83], heart disease (1.35 [1.00, 1.83]), and stroke (1.50 [1.03, 2.19]). The subgroup analysis by age at baseline (< 60 vs. ≥ 60 years) showed that the associations appeared to be evident among men < 60 years, particularly for CVD (1.82 [1.24, 2.69]) and heart disease (1.72 [1.06, 2.79]). However, interaction tests suggested the associations were not significantly modified by age (P for interaction > 0.10 for all outcomes).

CONCLUSION

In Chinese men, BPH was associated with higher risks of CVD, heart disease and stroke, particularly among men aged < 60 years.

The effect of Trigonella foenum-graecum extract on prostate-specific antigen, and prostate function in otherwise healthy men with benign prostate hyperplasia

The aim of this trial was to evaluate the effect of a standardised Trigonella foenum-graecum (Fenugreek) extract on the symptoms of benign prostate hyperplasia (BPH) using a double-blind randomised placebo controlled design. The study recruited 100 healthy males aged between 45 and 80 years with symptoms of BPH who recorded a minimum score of eight on the International Prostate Symptom Score. Participants were randomised to an oral dose of either 600mg Trigonella foenum-graceum per day or placebo for 12 weeks. The primary outcome measure was the International Prostate Symptom Score total and subdomain scores. The secondary outcomes were serum levels of the hormones (testosterone, free testosterone, and sex hormone binding globulin) prostate-specific antigen, and safety markers. The results indicated that Trigonella foenum-graceum did not have an effect on improving the symptoms of BPH. Hormone levels, safety markers, and prostate-specific antigen remained unchanged and within normal limits after 12 weeks, which adds to the safety profile of this specialised extract.

Effect of Paecilomyces tenuipes Extract on Testosterone-Induced Benign Prostatic Hyperplasia in Sprague-Dawley Rats

Benign prostatic hyperplasia (BPH) is one of the major public health concerns, which has a high prevalence rate and causes significant decline in men’s quality of life. BPH is highly related to sexual hormone metabolism and aging. In particular, dihydrotestosterone (DHT), to which testosterone is modified by 5α-reductase (5AR), has a significant effect on BPH development. DHT binds to an androgen receptor (AR) and steroid receptor coactivator 1 (SRC-1); then, it induces the proliferation of a prostate cell and expression of prostate specific antigen (PSA). Paecilomyces tenuipes (P. tenuipes) is a mushroom that has been popularized by the artificial cultivation of fruiting bodies based on silkworms by researchers from the Republic of Korea. In a previous study, we identified the effect of PE on PSA mRNA expression in LNCaP cells. This suggests that PE may have an inhibitory effect on androgen signaling. Therefore, we confirmed the expression of androgen signaling-related factors, such as AR, SRC-1, and PSA in LNCaP. Furthermore, we confirmed the androgen signaling inhibitory effect of PE using the testosterone propionate (TP)-induced BPH rat model. A BPH rat model was established with a four-week treatment of daily subcutaneous injections of testosterone propionate (TP, 3 mg/kg) dissolved in corn oil after castration. The rats in the treatment group were orally gavaged P. tenuipes extract (PE), finasteride (Fi), or saw palmetto extract (Saw) with TP injection. DHT induced an increase in the expression levels of AR, SRC-1, and PSA proteins in LNCaP cells. On the contrary, the PE treatment reduced the expression levels. In vivo, the BPH group showed an increase in prostate size compared with the control group. The PE gavaged group showed a decrease in prostate size compared with the BPH group. In addition, the protein expressions of AR, 5AR2, and PSA were significantly lower in the PE gavaged group than BPH group in prostate tissue. These results suggest the beneficial effects of PE on BPH via the modulation of AR signaling pathway.

HBX-6, Standardized Cornus officinalis and Psoralea corylifolia L. Extracts, Suppresses Benign Prostate Hyperplasia by Attenuating E2F1 Activation

Background: The aim of this study was to simplify and identify the contents of the herbal formula, HBX-5. This study was carried out to evaluate the therapeutic effects of HBX-6 in a mouse model of benign prostatic hyperplasia (BPH). Based on in vitro, we selected a candidate, reconstituted an experimental agent and investigated the effects on testosterone-induced BPH rats. Cell viability was determined by MTT assay in RWPE-1 and WPMY-1 cells. The expression of androgen receptor (AR) was measured in dihydrotestosterone-stimulated RWPE-1 and WPMY-1 cells. BPH was induced in mice by a subcutaneous injection of testosterone propionate for four weeks. Animals were divided into six groups: Group 1, control mice; Group 2, mice with BPH; Group 3, mice with BPH treated with finasteride; Group 4, mice with BPH treated with 200 mg/kg HBX-5; Group 5, mice with BPH treated with 100 mg/kg HBX-6; and Group 6, mice with BPH treated with 200 mg/kg HBX-6. Changes in prostate weight were measured after treatments, and the thickness of the epithelium was evaluated. The expression levels of proteins associated with prostatic cell proliferation and cell cycle-related proteins were determined. Based on previous reports and in vitro results, we selected Cornus officinalis and Psoralea corylifolia among HBX-5 components and reconstituted the experimental agent, and named it HBX-6. The result represented a new herbal formula, HBX-6 that suppressed the pathological alterations in BPH and showed a marked reduction in proliferation-related protein expression compared to mice with BPH. Our results indicate that HBX-6 has a better therapeutic effect in the BPH murine model than those of HBX-5 and finasteride, suggesting the role of HBX-6 as a new BPH remedial agent.

Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline

PURPOSE

Male lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is common in men and can have negative effects on quality of life (QoL). It is the hope that this Guideline becomes a reference on the effective evidence-based surgical management of LUTS/BPH.

MATERIALS AND METHODS

The evidence team searched Ovid MEDLINE, the Cochrane Library, and the Agency for Healthcare Research and Quality (AHRQ) database to identify studies indexed between January 2007 and September 2017. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (table 1 in supplementary unabridged guideline, http://jurology.com/).

RESULTS

This Guideline provides updated, evidence-based recommendations regarding management of LUTS/BPH utilizing surgery and minimally invasive surgical therapies; additional statements are made regarding diagnostic and pre-operative tests. Clinical statements are made in comparison to what is generally accepted as the gold standard (i.e. transurethral resection of the prostate [TURP]-monopolar and/or bipolar). This guideline is designed to be used in conjunction with the associated treatment algorithm.

CONCLUSIONS

The prevalence and the severity of LUTS increases as men age and is an important diagnosis in the healthcare of patients and the welfare of society. This document will undergo additional literature reviews and updating as the knowledge regarding current treatments and future surgical options continues to expand.

Adherence of Indonesian urologists to practice guidelines for the management of benign prostatic hyperplasia

Background

Clinical guideline is built to provide consistent, efficient, and high quality of medical care based on recent evidence. This study aimed to investigate the adherence of Indonesian urologists to clinical guidelines for the management of benign prostatic hyperplasia (BPH).

Materials and methods

This was a cross-sectional study using questionnaire conducted between January and June 2017. Respondents were Indonesian urologists registered as members of Indonesia Urological Association and had already practice in urology for at least 6 months. Questionnaires were sent via e-mail and Google Form. The level of adherence was measured using scoring system decided by authors' agreement. All data were processed using SPSS, version 23, and presented in descriptive fashion.

Results

Of 352 urologists who fulfilled inclusion and exclusion criteria, 209 (59.4%) respondents returned the questionnaire. Most of respondents (95.2%) used Indonesia Urological Association BPH guidelines as their clinical practice guidance. Routinely performed recommended examination, such as symptom scoring system, digital rectal examination, urinalysis, uroflowmetry, postvoid residual urine, and prostate imaging were used by 89.9%, 92.5%, 70.4%, 50.8%, 53.3%, and 98.6% respondents, respectively. After patient is diagnosed with BPH, most of respondents considered medical therapy (99%), surgical therapy (93%), and watchful waiting (78.4), with alpha-blocker as the drugs most preferred by respondents. For indication to perform surgery for BPH, only bladder stones, decreased renal function, and trial without catheter failure were considered by more than 85% of respondents. Open prostate surgery was performed by 54.8% respondents for the following reasons: large prostate volume, presence of bladder stone, unavailability of endourology equipments, abnormality of bladder, and residency training program. At last, this study found median (minimum–maximum) of Indonesian urologists adherence level toward BPH guidelines is 78.5% (28.6%–100%).

Conclusions

In general, Indonesian urologists have a good adherence toward guidelines. However, there is still wide variation of their adherence to it.