© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
Treatment: informed surveillance
This is a good choice for the patient with obstructive
symptoms, but not enough bother to choose or accept any
sort of therapeutic intervention.
In reality, patients often feel that taking medications
or the risks of surgery are of greater concern than
symptoms or even some of the associated quality-
of-life issues.
30
One simple question at this point
may be enough: “Are your symptoms bad enough
that it would justify taking a medication each day or
having a surgical procedure?” This should be asked
in such a way that the patient is aware that they can
come back at any time if, and when, they are ready
for intervention.
Informed surveillance refers to the idea that the
patient is knowledgeable about the symptoms or the
complications that may occur. This is reasonable if
patient has not developed complications of BPH, such
as BOO, hydroureter, hematuria, hydronephrosis,
acute urinary retention (AUR), urinary tract infections
(UTIs), bladder hypertrophy, or others.
31
It is critical for
the PCP to explain that BPH is a progressive disease,
point out the risk factors that have been identified
in the evaluation and that he should speak to the
physician if the symptoms worsen. In a longitudinal
study, Djavan found that over a 4 year time span 87%
of men with mild symptoms went on to experience
worsening symptoms while 13% of men with mild
symptoms experienced stability or improvement of
their symptoms.
32
Understanding the risk factors puts
the patient and the PCP in a good position to anticipate
future issues.
The reasons why some patients choose treatment
while others do not is certainly an interesting issue
for speculation. Patients will often acknowledge their
symptoms and seek to verify that a serious disease is
not the cause (for example, prostate cancer). Many
men are reluctant to reveal LUTS due to fear that
these symptoms represent a serious or life-threatening
problem. An education from his PCP regarding the
cause of his symptoms will both enlighten and relieve
the patient.
Those patients who opt for informed surveillance
may benefit from lifestyle changes. Limitations of
fluids, bladder training focused on timed and complete
voiding, and treatment of constipation may help the
patient regulate urinary symptoms. Similarly, a review
of the patient’s medication list will help identify
opportunities to modify (i.e., change the timing of
diuretics) or avoid (i.e., decongestants) medications
that may impact symptoms of BPH.
15
Treatment: alpha-blockers
Single medication therapy with an alpha-blocker is
appropriate for the symptomatic patient who has identified
bother and has a PSA of < 1.5 ng/mL.
Initiating treatment with an alpha-blocker, or alpha
antagonist, has been an option for many years. The
currently recommended medications include the non-
selective second generation alpha-blockers (doxazosin
and terazosin) and more uroselective third generation
alpha-blockers (alfuzosin, tamsulosin, silodosin),
Table 5.
33
By inhibiting alpha1-adrenergic-mediated
contraction of prostatic smooth muscle, alpha-blocker
therapy relieves the bladder outlet obstruction.
21
This
is termed the “dynamic” component of obstruction and
thesemedications are the “openers”. Formanymen, this
is sufficient for satisfactory relief of symptoms. Patients
with smaller prostates (< 30mL) tend to benefit themost
from this monotherapy. Treatment failure with alpha-
blockers is higher inmenwith larger prostate volumes.
34
Medications in the alpha-blocker class work quickly
to relieve symptoms, usually within the first week
of therapy. Similar efficacy is seen with the alpha-
blocker class of medication as evidenced by indirect
comparisons as well as the limited direct comparisons.
However, while alpha-blockers improve symptoms,
they do not affect the progression of prostate growth.
These medications do not result in long term reduction
in the risk of AUR or BPH-related surgery.
34
Common side effects reported with alpha-blocker
therapy include orthostatic hypotension, dizziness,
tiredness, ejaculatory problems and nasal congestion.
21
The uroselective alpha-blockers seem to have fewer
side effects than the non-selective ones; however, they
can be associated with light-headedness and a higher
incidence of ejaculatory dysfunction. An additional
risk, identified in 2005, is floppy iris syndrome noted
during cataract surgery.
35
As a result of this risk,
ophthalmologists preparing the patient for cataract
surgery should be aware of current alpha-blocker use.
Treatment: phosphodiesterase type 5
inhibitors (PDE5i)
Single medication therapy with a PDE5i is appropriate for
the symptomatic patient who has identified obstruction,
bother and has a PSA of < 1.5 ng/mL. The potential benefit
of this therapy on male sexual function should be considered.
The PDE5i class is relatively newas a treatment for BPH-
LUTS. Vardenafil, sildenafil and tadalafil have all been
studied on their effects in reducing LUTS, however, in
19
Apractical primary care approach to lower urinary tract symptoms caused by benign prostatic hyperplasia (BPH-LUTS)
