{"id":247,"date":"2019-10-09T20:38:21","date_gmt":"2019-10-09T15:08:21","guid":{"rendered":"https:\/\/medicineplexus.com\/?p=247"},"modified":"2019-10-09T20:38:21","modified_gmt":"2019-10-09T15:08:21","slug":"medical-treatment-of-benign-prostatic-hyperplasia","status":"publish","type":"post","link":"https:\/\/medicineplexus.com\/medical-treatment-of-benign-prostatic-hyperplasia\/","title":{"rendered":"Medical Treatment of benign prostatic hyperplasia"},"content":{"rendered":"\n<p><strong>Medical treatment of benign prostatic\nhyperplasia<\/strong><\/p>\n\n\n\n<p>Prostatic enlargement with increased age is\ncorrelated with smooth muscle hyperplasia and may eventually lead to bladder\noutlet obstruction (BOO).<\/p>\n\n\n\n<p>The most common presentation of subjective\nBPH-associated symptoms is lower urinary tract symptoms (LUTS). <\/p>\n\n\n\n<p>LUTS may further be classified <\/p>\n\n\n\n<ul><li>as obstructive symptoms: urine hesitancy, straining, weak flow, prolonged voiding, partial or complete urinary retention, and urinary incontinence. <\/li><li>irritative symptoms: urinary frequency, urgency, nocturia, dysuria, and decreased void volume.<\/li><\/ul>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"683\" height=\"373\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-73.png?w=683\" alt=\"\" class=\"wp-image-249\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-73.png 683w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-73-300x164.png 300w\" sizes=\"(max-width: 683px) 100vw, 683px\" \/><\/figure><\/div>\n\n\n\n<p><strong>General Considerations<\/strong><\/p>\n\n\n\n<p><strong>Behavioral interventions<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<p>In patients with symptoms of (BPH) who do not have any\ndiscomfort and have no evidence of complications (such as bladder outlet\nobstruction, renal insufficiency, or recurrent infection), pharmacologic\ntreatment may not be necessary.<\/p>\n\n\n\n<p>These patients may be monitored and advised regarding\nbehavioral modification.<\/p>\n\n\n\n<p>Behavioral\nmodification may be helpful for all patients. <\/p>\n\n\n\n<ul><li><strong>voiding\nin the sitting position<\/strong> (rather than standing)<\/li><li><strong>Avoiding\nfluids prior to bedtime<\/strong> or before going out<\/li><li><strong>Reducing<\/strong>\nconsumption of mild diuretics such as <strong>caffeine\nand alcohol<\/strong><\/li><li><strong>Double voiding to empty the bladder<\/strong> more\ncompletely<\/li><\/ul>\n\n\n\n<p>In one randomized trial, <strong>men given an educational intervention<\/strong> that included the teaching of\nbehavioral modifications were significantly <strong>less likely to experience treatment failure (increase in International\nProstate Symptom Score [IPSS]<\/strong> or requirement for medication) compared with\nmen who chose watchful waiting alone <\/p>\n\n\n\n<p><strong>Indications for medical treatment<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<p>The decision to medically \u00e0 balances the\nseverity of the patient&#8217;s symptoms with the potential side effects of therapy. <\/p>\n\n\n\n<p>Unless patients have developed bladder outlet\nobstruction, BPH only requires therapy if symptoms have a significant impact on\na patient&#8217;s quality of life <\/p>\n\n\n\n<p>In\naddition to bladder outlet obstruction, there are several other situations in\nwhich patients should be referred to a urologist for evaluation prior to the\ninitiation of medical therapy:<\/p>\n\n\n\n<p>\u25cfSymptoms in the setting of <strong>autonomic or severe peripheral neuropathy<\/strong><br>\u25cfSymptoms following invasive treatment of the urethra or prostate<br><strong>\u25cfMen &lt;45 years old<\/strong><br>\u25cfAbnormality on the prostate exam (nodule, induration, or asymmetry)<br>\u25cfPresence of <strong>hematuria<\/strong> in the absence of infection<br>\u25cfMen with <strong>incontinence<\/strong><br>\u25cfSevere symptoms (IPSS \u226520) <\/p>\n\n\n\n<p><strong>Overview<\/strong>\u00a0\u2014\u00a0<\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"693\" height=\"619\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-74.png?w=693\" alt=\"\" class=\"wp-image-250\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-74.png 693w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/10\/image-74-300x268.png 300w\" sizes=\"(max-width: 693px) 100vw, 693px\" \/><\/figure><\/div>\n\n\n\n<p>In\npatients with <strong>mild <\/strong>(International\nProstate Symptom Score [IPSS] &lt;8<strong>) to\nmoderate<\/strong> (IPSS 8-19) symptoms of BPH, we suggest <strong>initial treatment with an alpha-1-adrenergic antagonist monotherapy<\/strong>\n<\/p>\n\n\n\n<p><strong>Alpha-1-adrenergic antagonists provide\nimmediate therapeutic benefits<\/strong>, while <\/p>\n\n\n\n<p><strong>5-alpha-reductase inhibitors<\/strong>\nrequire <strong>long-term treatment for\nefficacy.<\/strong> <\/p>\n\n\n\n<p>Patients\nwho experience side effects, such as hypotension, with alpha-1-adrenergic\nantagonists but still desire medical therapy for their BPH can be switched to\n5-alpha-reductase inhibitors for monotherapy. <\/p>\n\n\n\n<p>Treatment\nwith 5-alpha-reductase inhibitors requires 6 to 12 months before symptom\nimprovement. <\/p>\n\n\n\n<p><strong>Alternative options<\/strong> are\navailable in specific populations of patients. <strong>Anticholinergic agents<\/strong> can be used in men who have <strong>predominately irritant symptoms<\/strong>, and <\/p>\n\n\n\n<p>P<strong>hosphodiesterase-5 inhibitors<\/strong> are an option in men who also have <strong>erectile dysfunction<\/strong>. <\/p>\n\n\n\n<p>In\nmen with severe symptoms (IPSS \u226520), it may be reasonable to initiate therapy\nwith a combination of an alpha-1-adrenergic antagonist and a 5-alpha-reductase\ninhibitor. <\/p>\n\n\n\n<p>Medical\nmanagement of BPH should be individualized based upon the nature and severity\nof symptoms and drug side effect profiles.<\/p>\n\n\n\n<p><strong>Alpha-1-adrenergic antagonists<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<ul><li>for initial therapy of symptomatic BPH in most patients. <\/li><li>act against the dynamic component of bladder outlet obstruction by rel<strong>axing smooth muscle in the bladder neck, prostate capsule, and prostatic urethra. <\/strong><\/li><li>Terazosin,\u00a0doxazosin,\u00a0tamsulosin,\u00a0alfuzosin, and\u00a0silodosin\u00a0are long-acting alpha-1-antagonists \u00e0 approved by the US Food and Drug Administration (FDA) <\/li><\/ul>\n\n\n\n<ul><li><strong>Efficacy\nand administration<\/strong>&nbsp;\u2014&nbsp;<\/li><\/ul>\n\n\n\n<p>Alpha-1-adrenergic\nantagonists appear to be more effective than 5-alpha-reductase inhibitors for\nshort- and long-term treatment of BPH. <\/p>\n\n\n\n<p>In a 2010 meta-analysis comparing alpha-adrenergic antagonist monotherapy versus\u00a0finasteride\u00a0(a 5-alpha-reductase inhibitor),\u00a0doxazosin\u00a0and\u00a0terazosin\u00a0were more effective in improving urinary symptoms compared with finasteride <\/p>\n\n\n\n<p>Tamsulosin\u00a0and finasteride were equally effective. <\/p>\n\n\n\n<p>terazosin,\u00a0doxazosin,\u00a0tamsulosin,\u00a0alfuzosin, and\u00a0silodosin: similar efficacy, although there have been few direct comparisons <\/p>\n\n\n\n<p>According\nto a 2017 meta-analysis, newer drugs \u00e0 silodosin\n\u00e0associated\nwith similar short-term symptom reduction but the greater risk for adverse\nevents (silodosin versus tamsulosin). Sexual side effects may be more common\nwith silodosin compared with other drugs<\/p>\n\n\n\n<ul><li>the choice of an agent may be based on cost, side effects (particularly hypotension), and potential medication interactions (especially with phosphodiesterase-5 inhibitors). <\/li><li>Prazosin, a short-acting alpha-1-antagonist, is generally not used for BPH due to the need for frequent dosing and the potential for more cardiovascular side effects. <\/li><li>Generally, it needs to be initiated at bedtime (to reduce postural lightheadedness soon after starting the medication), and the dose should be titrated up over several weeks.<\/li><\/ul>\n\n\n\n<p><strong>Side\neffects and interactions<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<p>\u25cf<strong>Hypotension\u00a0<\/strong>\u2013<strong> the <\/strong>most important side effects are orthostatic hypotension and dizziness.\u00a0<br>Tamsulosin,\u00a0alfuzosin, and\u00a0silodosin\u00a0have a lower potential to cause hypotension and syncope than either\u00a0terazosin\u00a0or\u00a0doxazosin.<br>These differential effects on blood pressure by different alpha-1-antagonists may be due to their differential blocking of alpha-1 adrenoceptor subtype <\/p>\n\n\n\n<p>\u25cf<strong>Interaction with phosphodiesterase-5 inhibitors<\/strong>\u00a0\u2013 The hypotensive effects of\u00a0terazosin\u00a0and\u00a0doxazosin\u00a0can be potentiated by concomitant use of the phosphodiesterase (PDE)-5 inhibitors\u00a0sildenafil\u00a0or\u00a0vardenafil. <\/p>\n\n\n\n<p>\u25cf<strong>Ejaculatory dysfunction<\/strong>\u00a0\u2013\u00a0Tamsulosin\u00a0and\u00a0silodosin, in particular, can affect ejaculation <br>Silodosin produces retrograde ejaculation in approximately 28 percent of patients<\/p>\n\n\n\n<p>\u25cf<strong>Other side effects&nbsp;<\/strong>\u2013 Other common side\neffects include headache, dizziness, and nasal congestion. <\/p>\n\n\n\n<p>Alpha-1-adrenergic antagonist use has also been\nassociated with <strong>intraoperative floppy\niris syndrome during cataract surgery.<\/strong> <\/p>\n\n\n\n<p><strong>5-alpha-reductase\ninhibitors<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<p>In\npatients who desire medical therapy but cannot tolerate alpha-1-adrenergic\nantagonists and do not have predominately irritant symptoms or concomitant\nerectile dysfunction, treatment with a 5-alpha-reductase inhibitor is\nreasonable. <\/p>\n\n\n\n<p>6 to\n12 months is generally needed before prostate size is sufficiently reduced to\nimprove symptoms.<\/p>\n\n\n\n<p>5-alpha-reductase\ninhibitors are more effective in men with larger prostates. <\/p>\n\n\n\n<p><strong>MOA<\/strong> \u00e0 act by\nreducing the size of the prostate gland and have demonstrated the potential for\na long-term reduction in prostate volume and the need for prostate surgery. <\/p>\n\n\n\n<p>The\ntype 2 form of <strong>5-alpha-reductase\ncatalyzes the conversion of testosterone to dihydrotestosterone in the\nprostate, hair follicles<\/strong>, and other androgen-sensitive tissues. <\/p>\n\n\n\n<p><strong>Efficacy<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<p>two 5-alpha-reductase inhibitors approved in the United States and Europe,\u00a0<strong>finasteride and\u00a0dutasteride.<\/strong> <\/p>\n\n\n\n<p><strong>Finasteride\u00a0\u2013 <\/strong><\/p>\n\n\n\n<ul><li>efficacy of\u00a0finasteride\u00a0appears to persist with long-term treatment. <\/li><li>improvements in symptom scores, maximal urinary flow rates, and prostate volume <\/li><li>decreased the probability of surgery and acute urinary retention<\/li><li>may also suppress gross hematuria that can occur in BPH<\/li><\/ul>\n\n\n\n<p><strong>Dutasteride\u00a0<\/strong>\u2013 <\/p>\n\n\n\n<ul><li>improved\nsymptom score and maximum flow rate while decreasing prostate volume, episodes\nof acute urinary retention, and need for surgical intervention <\/li><li>The\nmajor side effect \u00e0 &nbsp;sexual dysfunction.<\/li><\/ul>\n\n\n\n<p><strong>Administration<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<ul><li>Finasteride\u00a0can be initiated and maintained at 5 mg once daily.<\/li><li>Dutasteride\u00a0can be initiated and maintained at 0.5 mg once daily. <\/li><li>In contrast to the alpha-1-adrenergic antagonists, 5-alpha-reductase inhibitors do not require titration.<\/li><\/ul>\n\n\n\n<p><strong>Side\neffects<\/strong><\/p>\n\n\n\n<p>\u25cf<strong>Concern regarding prostate cancer<\/strong>\u00a0\u2013Because of this concern, however, the FDA recommends that, before starting 5-alpha-reductase inhibitors for the treatment of BPH, the patient should be assessed for other urological conditions, including prostate cancer <br>Prior to starting any treatment for BPH, we evaluate patients with a digital rectal exam (DRE) and a serum prostate-specific antigen (PSA)<br>monitor annually with a DRE and a PSA. <\/p>\n\n\n\n<p>\u25cf<strong>Sexual dysfunction<\/strong>&nbsp;\u2013 The major side effects \u00e0 decreased\nlibido and ejaculatory or erectile dysfunction <\/p>\n\n\n\n<p>A meta-analysis found that the risk of ejaculatory dysfunction was similar to finasteride and\u00a0dutasteride<\/p>\n\n\n\n<p>\u25cf<strong>Prostate-specific antigen<\/strong>&nbsp;\u2013 PSA\nconcentrations may decrease with 5-alpha-reductase inhibitor treatment. If a\npatient is being screened for prostate cancer, medication effect from\n5-alpha-reductase inhibitors should be taken into account when interpreting the\nPSA. <\/p>\n\n\n\n<p>\u25cf<strong>Depression<\/strong>&nbsp;\u2013 There have been concerns by\npatients and regulatory agencies about possible adverse psychiatric effects of\n5-alpha-reductase inhibitor therapy. Discontinuation of these medications may\nbe appropriate if depression develops.<\/p>\n\n\n\n<p><strong>Anticholinergic\nagents<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<ul><li>alternative\nmonotherapy for patients with predominately irritative symptoms (frequency,\nurgency, and incontinence) related to overactive bladder and without elevated\npostvoid residuals <\/li><\/ul>\n\n\n\n<ul><li>also\nused in combination therapy with alpha-adrenergic agents for patients with\npersistent symptoms of BPH who have irritative symptoms without elevated\npostvoid residuals. <\/li><\/ul>\n\n\n\n<ul><li>Tolterodine,\u00a0oxybutynin,\u00a0darifenacin,\u00a0solifenacin,\u00a0fesoterodine, and\u00a0trospium\u00a0are approved in the United States for overactive bladder. <\/li><\/ul>\n\n\n\n<ul><li>Alternatives\ninclude extended-release tolterodine, M3 selective drugs (eg, darifenacin,\nsolifenacin), or quaternary amines (eg, trospium).<\/li><\/ul>\n\n\n\n<ul><li>side\neffects <\/li><\/ul>\n\n\n\n<ul><li>inhibition\nof salivary secretion (dry mouth), <ul><li>blockade\nof the ciliary muscle of the lens to cholinergic stimulation (blurred vision\nfor near objects), <\/li><\/ul><ul><li>tachycardia,\n<\/li><\/ul><ul><li>drowsiness,\n<\/li><\/ul><ul><li>decreased\ncognitive function, and <\/li><\/ul><ul><li>inhibition\nof gut motility and constipation. <\/li><\/ul><ul><li>Anticholinergic\nagents are contraindicated in patients with gastric retention and angle-closure\nglaucoma.<\/li><\/ul><\/li><\/ul>\n\n\n\n<p><strong>Phosphodiesterase-5\ninhibitors<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<ul><li>reasonable to consider treatment with PDE-5 inhibitors in patients who have erectile dysfunction and mild or moderate symptoms (IPSS &lt;20) of BPH. <\/li><li>PDE-5 inhibitors can potentiate the hypotensive effects of alpha-1-adrenergic antagonists. <\/li><li>improve lower urinary tract symptoms with inconsistent effects on urine flow rates compared <\/li><li>A 2018 Cochrane review \u00e0 PDE-5 inhibitors were not superior to alpha-blockers, and there was no benefit of adding PDE-5 inhibitors to therapy with either alpha-blockers or 5-alpha reductase inhibitors.<\/li><\/ul>\n\n\n\n<p><strong>Combination Therapy<\/strong><\/p>\n\n\n\n<p>\u25cfFor patients with severe symptoms of BPH (International Prostate\nSymptom Score [IPSS] \u2265 20) <\/p>\n\n\n\n<p>who do not have an adequate response to maximal\nmonotherapy with an alpha-adrenergic antagonist, <\/p>\n\n\n\n<p>combination treatment with an alpha-adrenergic antagonist\nand 5-alpha-reductase inhibitor <\/p>\n\n\n\n<p>\u25cfFor men with low postvoid residual urine volumes and <strong>irritative symptoms (eg, frequency,\nurgency) that persist during treatment<\/strong> with an alpha-adrenergic antagonist,\nwe suggest <strong>combination treatment with an\nanticholinergic agent<\/strong>. <\/p>\n\n\n\n<p>\u25cfFor men with moderate symptoms of BPH and erectile dysfunction, treatment with daily\u00a0tadalafil\u00a0(5\u00a0mg\/day)alone or in combination with\u00a0tamsulosin\u00a0(0.4\u00a0mg\/day)\u00a0<\/p>\n\n\n\n<p><strong>Alpha-1-adrenergic antagonist and 5-alpha-reductase\ninhibitor<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<ul><li>In patients with severe symptoms of BPH <\/li><li>those who are known to have a large prostate (&gt;40 mL),\u00a0and\/or\u00a0<\/li><li>in those who do not get an adequate response to maximal dose monotherapy with an alpha-adrenergic antagonist, <\/li><\/ul>\n\n\n\n<p><strong>Alpha-1-adrenergic antagonist and anticholinergic<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<p>For men with low postvoid residual urine volumes and\nirritative symptoms (e.g., frequency, urgency) that persist during monotherapy\nwith an alpha-1-adrenergic antagonist or anticholinergic agent, we suggest\ncombination treatment with an alpha-1-adrenergic antagonist and an\nanticholinergic agent. <\/p>\n\n\n\n<p><strong>Surgical\nManagement<\/strong><\/p>\n\n\n\n<p>Patients who have persistent or progressive\nsymptoms despite combination therapy for 12 to 24 months should be considered\nfor surgical management. transurethral resection of the prostate (TURP)<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Medical treatment of benign prostatic hyperplasia Prostatic enlargement with increased age is correlated with smooth muscle hyperplasia and may eventually lead to bladder outlet obstruction (BOO). The most common presentation of subjective BPH-associated symptoms is lower urinary tract symptoms (LUTS). LUTS may further be classified as obstructive symptoms: urine hesitancy, straining, weak flow, prolonged voiding,[&#8230;]\n","protected":false},"author":3,"featured_media":250,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"","footnotes":""},"categories":[3],"tags":[],"_links":{"self":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/247"}],"collection":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/comments?post=247"}],"version-history":[{"count":0,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/247\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/media\/250"}],"wp:attachment":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/media?parent=247"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/categories?post=247"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/tags?post=247"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}