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© The Canadian Journal of Urology™; 18(Supplement 1); April 2011
to be motivated to seek treatment and would be more
likely to accept/comply with treatment.
3
Many reviews have shown that if BPH is untreated,
it often progresses, leading to worsening symptoms,
complications, the need for surgical intervention, and
a poorer quality of life.
5-7
The greatest predictable risk factors for progression
of BPH are: age older than 50, moderate prostate
symptoms (IPSS
≥
8), and prostate volume greater than
30 cc (or PSA
≥
1.5 ng/mL, where PSA is a surrogate
marker for prostate volume) at the time of diagnosis.
8-12
The following parameters are signs of BPH
progression: change in symptom score (IPSS), increase
in postvoid residual (PVR) urine volume, recurrent
urinary tract infections, hematuria, renal failure, onset
of urinary retention, and the need for surgery.
13
In my experience, in patients with BPH, the
most worrisome potential complications and the
complications that are most desirable to prevent
are urinary retention or the need for surgery. If
these complications can be avoided with medical
management, most men will accept that treatment
option.
The question that needs to be answered is: W
hich
medication or combination of medications will provide the
most reliable, improved, and prolonged symptom response
and the greatest reduction in the risk of progression of BPH
?
Management of BPH
Lifestyle modification
After a patient has presented to a primary care
physician and has been determined to have significant
LUTS, the first step in patient management is to
determine whether LUTS is caused by BPH causing
bladder outlet obstruction (BOO) or there is some
other cause.
The primary care physician can follow a relatively
simple diagnostic work up, to assess and stratify
the patient who presents with LUTS.
14
This work
up includes a complete patient history, a focused
physical examination, the IPSS questionnaire, and a
urinalysis and serum prostate-specific antigen (PSA)
test. The most important stratification assessment is
determining that a patient has an “enlarged prostate”
which can be accomplished by using serum PSA
level as a surrogate marker for prostate size. Today,
a prostate is considered to be “enlarged” if has a
minimum volume of 30 cc. It has been shown that a
PSAof 1.5 ng/mL or higher correlates with a prostate
volume of at least 30 cc.
15
To determine the treatment for men presenting
with LUTS that is secondary to BPH, and for which
there are no indications for immediate surgery,
15
Figure 1.
Treatment algorithm.
16
Benign prostatic hyperplasia and lower urinary tract symptoms: evidence and approaches for best casemanagement