Page 21 - Urology Update for Primary Care Physicians for 2013

© The Canadian Journal of Urology™; 19(Supplement 1); October 2012
Acknowledgement
The author would like to acknowledge Camilla Tajzler
(
Research Assistant at the McMaster Institute of Urology),
for assistance in preparing this manuscript.
Address correspondence to Dr. Anil Kapoor, Department of
Urology, McMaster University, St. Joseph’s Healthcare, 50
Charlton Avenue East, Hamilton, Ontario L8N 4A6 Canada
Benign prostatic hyperplasia (BPH)
management in the primary care setting
Anil Kapoor, MD
Department of Urology, McMaster University, Juravinski Cancer Centre, Hamilton, Ontario, Canada
KAPOOR A. Benign prostatic hyperplasia (BPH)
management in the primary care setting.
Can J Urol
2012;19(
Suppl 1):10-17.
Benign prostate hyperplasia (BPH) occurs in up to 50%
of men by age 50, and the incidence increases with age.
This common clinical problem is diagnosed by history,
including the International Prostate SymptomScore (IPSS)
questionnaire, and physical examination by digital rectal
examination (DRE).
Initial management for BPH includes lifestyle modification,
and smooth muscle relaxant alpha blocker therapy. Alpha
blockers usually take effect quickly within 3-5 days, and
have minimal side effects. Current commonly used alpha
blockers include the selective alpha blockers tamsulosin
(
Flomax), alfusosin (Xatral), and silodosin (Rapaflo). For
patientswith larger prostates, the 5-alpha reductase inhibitor
class (finasteride (Proscar) and dutasteride (Avodart)) work
effectively to shrink prostate stroma resulting in improved
voiding. The 5-ARI class of drugs, in addition to reducing
prostate size, also reduce the need for future BPH-related
surgery, and reduce the risk of future urinary retention.
Drugs from the phosphodiesterase-5 (PDE-5) inhibitor class
may now be considered for treating BPH. Once daily 5 mg
tadalafil has been shown to improve BPH-related symptoms
and is currently approved to treat patients with BPH.
Referral to a urologist can be considered for patients
with a rising prostate-specific antigen (PSA), especially
while on 5-ARI, failure of urinary symptom control
despite maximal medical therapy, suspicion of prostate
cancer, hematuria, recurrent urinary infections, urinary
retention, or renal failure.
Currently the primary care physician is armed with
multiple treatment options to effectively treat men with
symptomatic BPH.
Key Words:
benign prostatic hyperplasia (BPH),
pharmacotherapy, alpha blockers, 5-alpha reductase
inhibitors, combination therapy, phosphodiesterase-5
inhibitors
results in an enlarged prostate gland. As a result,
the prostatic urethra is compressed, which restricts
the flow of urine from the bladder. This interference
with urine flowmay cause uncomfortable symptoms
such as frequency, urgency, nocturia, intermittency,
decreased stream, and hesitancy, Figure 1. As BPH
progresses, complications—such as the development
of a urinary tract infection (UTI) or a bladder stone—
may occur. In severe cases patients may develop
urinary retention, kidney blockage (hydronephrosis),
or renal failure.
1
In this paper, which is aimed at guiding the primary
care physician, we will summarize the epidemiology,
10
Introduction
Benign prostatic hyperplasia (BPH) is defined as
the proliferation of prostatic stromal cells, which