Traditionally, urologists have cared for patients with benign prostatic hyperplasia (BPH). However, because of demographic fluctuations, changes in the health care system, and the development of effective pharmacologic therapy for BPH, primary care physicians are increasingly involved not only in initial patient evaluation but also in continuing management.1-3 Here we provide guidelines for treatment of uncomplicated BPH—with special emphasis on medical therapies.
BPH is the most prevalent urologic disease in men, and it will become more common as the population ages.4 The key risk factors are advancing age and the presence of androgens. Clinically significant BPH that requires treatment will develop in only 50% of all men with an enlarged prostate5; however,more than half of men older than 60 years show histologic signs of BPH, and 1 in 4 are treated for symptomatic BPH by age 80.6
Practice guidelines issued by the Agency for Health Care Policy and Research in 1994 describe BPH as "primarily a quality-of-life disease" and urge that it be viewed largely in terms of the degree of "bothersomeness" experienced by patients and the impact of the disease on their lives.6 However, the protracted course of BPH can result in complications, including acute urinary retention, recurrent urinary tract infection, recurrent gross hematuria, bladder stones, and renal insufficiency.
Discuss these issues with the patient, educate him about therapeutic options, and involve him in treatment decisions.6,7 If the patient requests advice or "surrenders" his decision-making ability, it is appropriate to recommend the optimal treatment or act as the patient's proxy.6
BPH symptoms occur most commonly in patients older than 40 years and develop gradually. Men of all races and cultures are affected.8 The most common reason patients seek treatment is that symptoms such as increased urinary frequency and nocturia become bothersome. Symptoms are commonly classified as "obstructive" (eg, hesitancy, straining, diminished and/or interrupted urinary stream, postmicturition dribbling, or sensation of incomplete emptying) or "irritative" (eg, increased frequency, nocturia, urgency, or urge incontinence). Most patients have a mix of both kinds of symptoms.
Differential diagnosis. Although BPH is the most common source of lower urinary tract symptoms (LUTS) in men older than 50 years, such symptoms have a variety of causes. Many patients may not have true BPH or prostatic enlargement; therefore, conditions that cause similar symptoms must be ruled out (Table 1).2
Other signs and symptoms to consider in generating the differential diagnosis include dysuria, polyuria, hematuria, and manifestations of malignancy; historical factors to consider include urethral syndromes (eg, sexually transmitted diseases, instrumentation, trauma); comorbid illness (eg, diabetes, congestive heart failure); and neurologic disease (eg, multiple sclerosis, Parkinson disease, spinal cord disease). In other disease processes, including malignancies, LUTS may develop more rapidly than in BPH; irritative symptoms predominate in these settings. In men younger than 50 years, symptoms are usually attributable to conditions other than BPH.2
Mechanisms that underlie symptoms. The obstructive symptoms of BPH appear to be caused by 2 different mechanisms: one is a static, mechanical obstruction resulting from the enlargement of the glandular tissue; the other is dynamic, the product of altered tone in the adrenergically innervated smooth muscle in the prostatic capsule and stroma as well as the bladder neck and trigone. Both components produce LUTS; fluctuations in symptoms result from changes in sympathetic nerve activity.2,9,10
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