© The Canadian Journal of Urology™; 19(Supplement 1); October 2012
Kapoor
12
symptoms from a score of 0 (not at all) to 5 (almost
always). The maximum IPSS is 35, and patients are
classified as having severe symptoms if they have
an IPSS of 20 to 35. After treatment is initiated, the
IPSS questionnaire can be used to monitor response
to therapy.
Physical examination of the prostate provides
information about the prostate’s size; any tenderness or
“
bogginess” suggests an infection, and any nodularity
suggests possible prostate cancer. A prostate cancer
nodule usually is hard and firm, and any asymmetry of
each lobe of the prostate should be further evaluated.
It is important to remember that current guidelines
recommend that even men with a normal serum
prostate-specific antigen (PSA) level should have an
annual DRE. The age at which to start annual DRE and
PSAis debatable, and ranges between 40 to 50 years of
age, and sooner in high risk men. Some hard, nodular
prostate cancers that do not produce PSA can only be
identified by a DRE.
A PSA blood test can be used as a marker of BPH
progression. A number of studies have shown that
PSA can be a surrogate marker for prostate volume.
5
PSA can be elevated in prostate cancer, prostate
infection, and BPH. It is important to remember that
all prostate cells make PSA, so patients with BPH and
large prostates will have higher PSAvalues than if they
had normal-sized prostates. For this reason, PSA can
be used as a marker for response to BPH treatment.
Urinalysis and culture tests are performed to rule
out infection as a possible cause of urinary symptoms.
Patient management
Lifestyle changes and herbal medicine
Lifestylemodifications may help improve BPH-related
symptoms. These include decreasing alcohol and
caffeine consumption, decreasing fluids before bedtime
to improve nocturia symptoms, and timed voiding.
One meta-analysis
6
suggested that the herbal
medication saw palmetto may result in a small
improvement in BPH-related symptoms, but more
recent studies
7
have suggested the benefit is no better
than placebo. Saw palmetto has minimal side effects,
and it appears to be a harmless herbal remedy that may
result in a slight benefit in a few patients.
Pharmacotherapy
The twomain classes of therapeutic agents used to treat
BPH are the alpha blockers and the 5-alpha reductase
inhibitors (5-ARIs).
Alpha blockers
The alpha blockers, Table 1, work to relax the smooth
muscle at the prostate and bladder neck by blocking
alpha–1a receptors. By relaxing the smooth muscle
at the prostate neck, the urinary channel is opened,
TABLE 1.
Alpha blockers for symptomatic benign prostatic hyperplasia (sBPH)
Name (Brand name)
Dose
Side effects/Notes
Second generation
Terazosin (Hytrin)
1
mg-10 mg daily*
First dose syncope; dizziness; tachycardia;
hypotension; headache; asthenia; rhinitis
Doxazosin (Cardura)
1
mg-8 mg daily*
Same as above
Third generation
Alfuzosin
10
mg daily with food
Dizziness; headache; minimal cardiovascular
(
Xatral [Canada]
effect; less ejaculatory dysfunction than
Uroxatral [US])
tamsulosin
Tamsulosin
Flomax CR: 0.4 mg daily
Ejaculatory dysfunction; rhinitis
(
Flomax CR,
(
with or without food)
generic capsules)
Generic capsules:
0.4
mg-0.8 mg daily with food
Silodosin (Rapaflo)
8
mg daily;
Well tolerated; minimal retrograde ejaculation
4
mg daily with CrCl 30-50 mL/min
and cardiovascular side effects
*
Dose titrated weekly to desired response, monitor blood pressure
CrCl = creatinine clearance
