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© The Canadian Journal of Urology™; 18(Supplement 1); April 2011
Address correspondence to Dr. Jack Barkin, Chief of Staff,
Humber River Regional Hospital, 960 LawrenceAvenueWest,
Suite 404, Toronto, Ontario M6A 3B5 Canada
Benign prostatic hyperplasia and lower
urinary tract symptoms: evidence and
approaches for best case management
Jack Barkin, MD
Humber River Regional Hospital, University of Toronto, Toronto, Ontario, Canada
BARKIN J. Benign prostatic hyperplasia and lower
urinary tract symptoms: evidence and approaches
for best case management. The Canadian Journal of
Urology. 2011;18(Supplement 1):14-19.
Significant lower urinary tract symptoms (LUTS) are
very common in men over age 50. It is appropriate for the
primary care physician to perform the work up to confirm
that benign prostatic hyperplasia (BPH) is causing the
LUTS. If the physician determines that the patient has
moderate symptoms (an International Prostate Symptom
Score [IPSS]
≥
8), moderate “bother” (
≥
3 on the IPSS
“bothersome index” question), and an enlarged (> 30 cc)
prostate, then the most effective treatment is combination
therapy with an alpha blocker and 5-alpha reductase
inhibitor (5-ARI) at the time of confirmed BPH diagnosis.
This combination will provide the most dramatic, early
symptom response, the most sustained symptom response,
and the most durable, reliable prevention of long term
sequelae (acute urinary retention or the need for surgery),
if the patient is compliant with taking the combination
therapy.
KeyWords:
benignprostatic hyperplasia, BPH, LUTS
a question about quality of life, which can also be
called the “bothersome index” or “motivational index”
question. That question asked, “
If you were to spend the
rest of your life with your urinary condition the way it is
now, how would you feel about that?”
From this was born the International Prostate
Symptom Score (IPSS), which became the gold
standard outcome measurement for most clinical
trials that assessed responses to interventions for
the management of BPH.
4
IPSS symptom scores
range from 0 to 8 for “mild” symptoms, 9 to 20 for
“moderate” symptoms, and 21 to 35 for “severe”
symptoms. Responses to the quality-of-life question
range from 0 (delighted) to 6 (terrible).
Clinical trials for the treatment of BPH and LUTS
look for ”symptom response” that is the change in IPSS
scores from baseline after measured at a specified time
after beginning of treatment. Patients act as their own
controls. The trials showed that to perceive a clinical
benefit from a therapy, patients needed a minimum
3-point improvement in IPSS. In addition, if a patient’s
score on the quality-of-life question was 3 or higher,
the patient was “bothered enough” by the symptoms
Background
As men age, they have a significant risk of having
symptoms associated with an enlarged prostate. Age
is the greatest risk factor for the presentation of lower
urinary tract symptoms (LUTS), and benign prostatic
hyperplasia (BPH) is one of themost common causes of
LUTS. It is estimated that 50%percent of men over age
60 and almost 90% of men in their 90s have symptoms
froman enlarged prostate and require therapy for this.
1
However, BPH and LUTS are also found in younger
men. Bushman reported that 18% of men in their 40s
report significant bother from enlarged prostate for
which they may request medical relief.
2
Almost 20 years ago, Michael J. Barry, MD,
suggested that by using a simple questionnaire, which
was later validated, physicians could quantify urine
storage and voiding symptoms reported by patients
with BPH or LUTS.
3
The questionnaire also included
14