© The Canadian Journal of Urology™; 19(Supplement 1); October 2012
15
Benign prostatic hyperplasia (BPH) management in the primary care setting
Single-agent treatment of BPH and erectile
dysfunction
Erectile dysfunction (ED) and BPH often coexist
in aging men.
30,31
BPH not only causes prostatic
obstruction and bladder neck contraction, it may also
alter smooth muscle relaxation, reduce blood flow,
and reduce the function of nerves and endothelium.
32
Phosphodiesterase-5 (PDE-5) promotes smooth
muscle contraction; therefore, PDE-5 inhibitors may
have a role in smooth muscle relaxation in BPH
and may provide symptom relief. Recent studies of
oral PDE-5 inhibitors—including tadalafil (Cialis),
vardenafil (Levitra), and sildenafil (Viagra)—have
demonstrated significant improvements of LUTS in
patients with BPH.
33-37
Adosage of 5 mg tadalafil/day
significantly improved IPSS compared to placebo,
38
with improvement onset occurring within 2 weeks.
Although urodynamic profiles were not significantly
improved with daily tadalafil, patients’ symptom
scores improved. Side effects included headache, back
pain, facial flushing, dyspepsia, and nasopharyngitis.
In Canada, 5 mg daily tadalafil (Cialis) was approved
for the treatment of BPH and ED, as of June 2012.
Surgical therapy
If patients continue to be bothered by their urinary
symptoms despite medical therapy, the next options
include minimally invasive surgical therapies.
The most common surgical procedure for BPH is
transurethral resection of the prostate (TURP). This
involves removing the prostatic urethra and “coring”
the prostate, which creates a channel for the patient to
void through. Risks from this surgery include bleeding
(
with a risk of blood transfusion), permanent sexual
side effects (such as retrograde ejaculation and less
commonly, ED), UTIs, and, rarely, urinary incontinence.
Numerous energy sources have been studied and
used for TURP. These include cautery, holmium laser
(
holmium laser enucleation of the prostate [HoLEP],
or holmium laser ablation of the prostate [HoLAP]),
Nd-YAG visual laser-assisted prostatectomy (VLAP),
GreenLight laser (potassium-titanyl-phosphate [KTP]),
and photoselective vaporization (PVP). In general,
TURP is the gold standard for surgical management
of BPH.
Guidelines and algorithms
The CanadianUrologicalAssociation (CUA) guidelines
for the management of BPH
39
are available on the CUA
website.
References
1.
McConnell JD, Bruskewitz R, Walsh P et al. The effect of
finasteride on the risk of acute urinary retention and the
need for surgical treatment among men with benign prostatic
hyperplasia. Finasteride Long-Term Effi cacy and Safety Study
Group.
N Engl J Med
1998;338(9):557-563.
2.
Roehborn CG. Benign prostatic hyperplasia: an overview.
Rev Urol
2005;7(9):
S3-S14.
Reasons for referral to a urologist
Once treatment for BPH has been initiated, a referral
to a urologist would be indicated in the following
instances:
•
Rising PSA, especially while on a 5-ARI such as
finasteride or dutasteride
•
Failure of urinary symptom control despite
combination therapy
•
Suspicion of prostate cancer, from a prostate exam
and/or elevation in serum PSA levels
•
Hematuria (microscopic or gross)
•
Recurrent UTIs
•
Urinary retention
•
Renal insufficiency or renal failure fromobstruction
Summary
The standard therapy for managing a patient with
BPH is initiating an alpha blocker with a quick onset
of action, between 3 to 5 days. Selective alpha blockers
include tamsulosin, alfuzosin, and more recently,
silodosin. For patients with larger prostates, the
addition of a 5-ARI such as finasteride or dutasteride
may be considered, to reduce prostate volume, reduce
the risk of acute urinary retention, and decrease the risk
of future prostate-related surgery. After 6 to 9 months
of combination therapy with an alpha blocker and a
5-
ARI, consideration can be given to stopping the alpha
blocker. In addition to treating patients with BPH
with drugs from the 5-ARI class and the alpha blocker
class, drugs from the PDE-5 inhibitor class may now
be considered for treating BPH. Once daily tadalafil 5
mg has been shown to improve BPH-related symptoms
and is a current treatment option for BPH patients.
Disclosure
Dr. Anil Kapoor research funding and advisor for
Pfizer, Novartis, GlaxoSmithKline.
