Benign Prostatic Hyperplasia

Philippine Urological Association, Inc.

3/F, Philippine College of Surgeons Bldg., 992 EDSA, Quezon City
Tel. No. 454-4439; Telefax No.: 925-6740
Email: [email protected]; [email protected]
Website:www.puanet.org.ph

Executive Council 2009

President Dennis P. Serrano, MD

Vice President Telesforo E. Gana, Jr., MD
Secretary Jaime C. Balingit, MD
Treasurer Raul Winston P. Andutan, MD
Auditor Marcelino L. Morales, Jr., MD

Council Members Jose Rufo U. Campaña, MD

Edgardo L. Reyes, MD

Adviser Ariel A. Zerrudo, MD

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 Benign Prostatic Hyperplasia
leads to a better treatment outcome and predetermine
Benign Prostatic Hyperplasia the treatment of choice

Background Recommended
• Medical History to identify other causes of voiding
Benign Prostatic Hyperplasia (BPH) is one of the most dysfunction or comorbidities that may complicate
common benign disease in men that can lead to prostatic treatment1
enlargement, prostatic obstruction and/or lower urinary • Symptom score (International Prostate Symptom
tract symptoms. Pathologic changes are found in 88% Score) for all patients as baseline guide and evalua-
of men aged 80 years or older and lower urinary tract tion for treatment response1
symptoms reported in almost 50% of men aged 50 years • Physical Examination which includes a focused neu-
or older in the general population. rologic examination and digital rectal exam1
• Urinalysis used as screening test for pyuria, hematu-
The etiology is multi-factorial with age, PSA and prostate ria, glucosuria, etc.1
volume being the true factors related to the development
of the disease. A group of patients at increased risk of Optional
progression can be identified based on these specific risk • Creatinine1
factors. For those, it might be appropriate to initiate early • PSA
treatment. However, for some other patients, surgical - For patients with at least a 10 year life expectancy
treatment may be the best option. and for whom knowledge of the presence of prostate
cancer would change management
Recent advances in screening and treatment are now - For whom the PSA measurement may change the
available for management of patients in the Philippine set- management of the patient’s voiding symptoms
ting. Clinical practice guidelines of the European Associa- • Uroflowmetry - specially for patients with a complex
tion of Urology and the American Urological Association medical history and in those desiring invasive therapy,
were reviewed and modified to fit the needs of our local Qmax >15 mL/sec is usual in men between 25 to 60
areas. Though mostly based on scientific evidence from years old, important in differentiating other causes of
literature, opinion of the majority of the Committee is given obstruction2b
credibility since these urologists are the ones exposed to • Pressure flow studies2b
the patients at the grassroots level. Consideration is also • Ultrasound (to include post void residual volume)2a
given to the economic and legal factors in doing these • Excretory urography is not recommended unless the
guidelines. Caution is advised in using these guideline patient has hematuria, UTI, a history of urolithiasis or
and no physician can be held liable for diverting from the urinary tract surgery2a
following protocol. (Lesson 29 Vol 12) • Cystoscopy2a

Category 1: Uniform consensus among the members Initial Management

of the PHC, based on high-level evidence
Patients with mild symptoms
and experience, that the recommendation
is appropriate
Watchful waiting is the treatment of choice in patients
with mild symptoms of BPH (AUA Symptom Score <7)
Category 2A: Uniform consensus, based on lower-level
and patients with moderate or severe symptoms who are
evidence including individual clinical expe-
not bothered by their symptoms (i.e. do not interfere with
rience and local practice, that the recom-
the daily activities of living)1
mendation is appropriate
Patients with moderate to severe symptoms
Category 2B: Non-uniform consensus (but no major
disagreement), based on lower-level
Treatment options for patients with bothersome moder-
evidence, that the recommendation is
ate to severe symptoms of BPH (AUA Symptom Score
appropriate
>8) include watchful waiting and the medical, minimally
invasive or surgical therapies1
Category 3: Major disagreement that the recommenda-
tion is appropriate
Explain the benefits and harms of the BPH treatment op-
tions (including watchful waiting) to patients with moder-
Assessment of men with BPH ate to severe symptoms (AUA Symptom Score >8) who
are bothered enough to consider therapy.
The presented recommendations apply only to men
above 40 years of age without significant risk of non-BPH Treatment Recommendations
related origin of LUTS. Men with concomitant neurological
diseases, younger age, prior lower urinary tract disease Watchful Waiting
or surgery usually require a more intensive work-up not - indicated for patients with mild or non-bothersome
included here. Accurate and early diagnosis of BPH symptoms1
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Benign Prostatic Hyperplasia
Medical Treatment Other technologies NOT RECOMMENDED

a. Alpha adrenergic blockade therapy • Prostatic stents are associated with significant com-
Alfuzosin, tamsulosin and terazosin are appropriate plications such as encrustation, infection and chronic
treatment options for patients with LUTS due to BPH pain.
and are believed to have equal effectiveness1
• Balloon dilatation is not recommended for patients with
b. 5-alpha reductase therapy symptoms of BPH.
Finasteride and dutasteride are:
• Phytotherapeutic agents and other dietary supplements
• appropriate and effective treatments for patients cannot be recommended for treatment of BPH
with LUTS associated with demonstrable prostatic
enlargement1

• indicated for patients with symptomatic prostatic
enlargement but no bother, to prevent disease
progression1

• not appropriate for patients with LUTS without
evidence of prostatic enlargement1

c. Combination therapy
Concomitant use of alpha blocker and 5-alpha reduc­
tase inhibitor is an appropriate and effective treatment
for patients with LUTS associated with demonstrable
prostatic enlargement1

d. Optional treatment
Mepartricin2B

Minimally invasive therapy

a. Transurethral Microwave Heat Treatment

Prostatron, Targis, CoreTherm and Thermatrx are
effective in partially relieving symptoms in men with
BPH. Superiority of one specific device over another
has not been demonstrated in clinical trials to date

b. Transurethral Needle Ablation

Transurethral needle ablation is effective treatment
in partially relieving symptoms of BPH

Surgery

The patient may appropriately select a surgical inter-

vention as his initial treatment if he has bothersome
symptoms.

Patients who have developed complications of BPH are

best treated surgically (see table)

The choices of surgical approach (open or endoscopic)

and energy source (electrocautery vs laser) are techni-
cal decisions based on the patient’s prostate size, the
individual surgeon’s judgment and the patient’s comor-
bidities.1

20
 Benign Prostatic Hyperplasia
Indication for Surgery

Absolute • Refractory urinary retention
• Renal insufficiency due to BPH
• Bladder stones
• Bladder diverticulum due to obstruction
• Recurrent UTI
• Hematuria refractory to 5-alpha reductase inhibitor
Relative • Request for active management either initially or because there is
no improvement with medical management

Surgical Therapies

• Transurethral resection of the prostate
• Transurethral electrovaporization
• Transurethral incision of the prostate
• Transurethral holmium laser resection/enucleation
• Transurethral laser vaporization
• Transurethral laser coagulation (visual laser ablation)
• Open prostatectomy

Ideal Candidate for

Watchful Waiting

• mild symptoms (AUA symptom score <7)
• minimal to no bother (symptom score <7)
• minimal to no interference with quality of life (quality of life
score <3)
• no recurrent urinary tract infection
• no recurrent gross hematuria
• no bladder stone
• no urinary retention
• no renal insufficiency related to BPH
• peak flow rate >15 cc/sec
• relatively low post void residual urine

Indications for Simple Open

Prostatectomy

• prostate glands larger than 50 to 75 g, for which TURP is
considered inappropriate and risky
• large, symptomatic bladder diverticulum
• large, hard bladder stone that cannot be managed transurethrally

Alpha Blockers

Long acting selective alpha-1 • terazosin 1, 2, 5 mg
• doxazosin
Long acting selective alpha-1a • tamsulosin 0.2 mg
• alfuzosin 2.5, 10 mg

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Benign Prostatic Hyperplasia
References 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
American Urological Association Practice Guidelines Committee. AUA among men with benign prostatic hyperplasia. N Engl J Med 338:
Guideline on Management of Benign Prostatic Hyperplasia (2003) J 557-563, 1998.
Urol 2003; 170: 530-47. Roehrborn CG, Marks LS, Fenter T, et. al. Efficacy and Safety of dutasteride
Napalkov P, Maisonneuve P and Boyle P: Worldwide patterns of prevalence in the four year treatment of men with benign prostatic hyperplasia. Adult
and mortality from benign prostatic hyperplasia. Urology 46 (3 suppl Urol 2004 63(4): 709-715.
A): 41-46, 1995. Will TJ, Ishani A., Stark G, et. al. Saw palmetto extracts for the treatment
Oesterling JE: Benign prostatic hyperplasia: A review of its histogenesis of benign prostatic hyperplasia: A systematic review. JAMA 1998; 280:
and natural history. Prostate Suppl 6: 67-73, 1996. 1604-1609.
Wasson JH, Reda DJ, Bruskewitz RC, Elinson J, Keller AM, Henderson Bent S, Kane CI, Shinohara K, et. al. A randomized trial of saw palmetto for
WG. A comparison of transurethral surgery with watchful waiting for the treatment of benign prostatic hyperplasia, J Urol 2005: 173(suppl
moderate symptoms of benign prostatic hyperplasia. N Eng J Med 4):443 [Abstract 1537] This randomized, placebo controlled trial did not
195; 332: 75-9. confirm efficacy for saw palmetto in the treatment of BPH.
Flannigan RC, Reda DJ, Wasson JH, Anderson RJ, Abdellatif M, Bruskewitz Mepartricin Investigator’s Brochure July 1997 Societa Prodotti Antibiotici
RC. 5 year outcome of surgical resection and watchful waiting for men Medical Department (as provided by drug representative).
with moderately symptomatic benign prostatic hyperplasia: A Department Levin RM, et. al. Effects of Tadenan pretreatment on bladder physiology
of Veterans Affairs cooperative study. J Urol 1998; 160: 12-7. and biochemisty following partial outlet obstruction. J Urol 1996 Dec.
Lepor, H, et. al. The Efficacy of terazosin, finasteride or both in Benign 156 (6): 2084-2088.
Prostatic Hyperplasia. The New England Journal of Medicine. August
1996; 335(8); 533-539.
Nickel, JC, et al. Update on the Use of Finasteride in BPH: long-term results.
Recent Advances in Prostate CA and BPH 1996; 23-26.
Nickel JC et. al. Efficacy of alfuzosin 10 mg OD in men with LUTS, BPH
and prostatitis-like symptoms. J Urol 2005; 175(Suppl 4): 446 [Abstract
1645].
A sub-analyses of a 6 month open label study (ALF-ONE study) suggested
that the alpha blocker alfuzosin significantly improved LUTS, bother,
sexual function and pain/discomfort on ejaculation in men with BPH and
prostatitis-like symptoms
Debruyne, FM, et. al. The International Terazosin Trial: A Multicentre Long-
Term Efficacy and Safety of Terazosin in the Treatment of BPH. European
Journal of Urology 1996 vol. 30;369-376.
McConnell JD, Roehrborn CJ, Bautista OM, et. al. Medical Therapy of Pros-
tatic Symptoms (MTOPS) Research Group. The long term effect of doxa-
zosin, finasteride, and combination therapy on the clinical progression of
benign prostatic hyperplasia. N Eng J Med 2003; 349:2387-2398.
Gormley, GS, et al The Effect of Finasteride in Men with BPH. The New
England Journal of Medicine 1992; 327:1185-1191
Brawer, MK. et. al. Terazosin in the Treatment of BPH. Archives of Family
Medicine 193; 2:929-935.
Lepor H. Long term evaluation of tamsulosin in benign prostatic hyperplasia:
Placebo controlled, double-blind extension of phase III trial. Tamsulosin
Investigator Group. Urology 1998:51:901-6.
Lepor H. Phase III multicenter placebo-controlled study of tamsulosin in
benign prostatic hyperplasia. Tamsulosin Investigator Group. Urology
1998;51:892-900.
Madrona, EP, Ong, G, et. al. Alpha Blockade Therapy in Alternating day
Dose in the Management of BPH. VMMC Journal of Surgery November
1999; 3:3-7.
De la Rosettes JJ, Madersbacher S, Alivizatos G, et. al. European Associa-
tion of Urology: Guidelines on benign prostatic hyperplasia: 2004.
De La Rosette J. Optimising Assessment and treatment decisions for men
with BPH. Eur Urol Suppl 2006; 271:1-6
Berry SJ, et. al. Journal of Urology 1984; 132:474-9 (Prevalence of BPH).
Roehrborn CG, McConnell J, Bonilla J, et. al. Serum prostate specific antigen
is a strong predictor of future prostate growth in men with benign prostatic
hyperplasia (PLESS). J Urology 163:13-20. 2000.
Roberts RO, et. al. J Urol 2000; 163: 107-13 (Peak flow rate and volume).
Arrighi HM, et. al. J Urol 1991; 3:4-8 (Risk of surgery).
Jacobsen SJ, Jacobsen DJ, Girman CJ, Roberts RO, Guess HA, Rhodes
T, et. al. Natural history of prostatism: Risk factors for urinary retention.
J Urol 1997; 158:481-7.
Djavan B, Marberger M. A meta-analysis on the efficacy and tolerability
of alpha1 adrenoreceptors antagonists in patients with lower urinary
tract symptoms suggestive of benign prostatic obstruction. Eur Urol
1999; 36:1-13.
Schulman CC, et. al. Eur Urol 1996; 29:145-54.
Medical Therapy of Prostatic Symptoms Steering Committee. J Urol 2002;
167:265.
Bartsch G. et. al. Eur Urol 2000; 37:367-80 (alpha reductase enzyme).
Níkel JC. Comparison of clinical trials with finasteride and dutasteride. Rev
Urol 2004; 6: suppl 31-9.
Roehrborn CG,Boyle P, Nickel J, et. al. Efficacy and safety of a dual inhibi-
tor or 5 alpha reductase types 1 and 2 [dutasteride] in men with benign
prostatic hyperplasia. Urology 2002; 60:434-41.

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 Benign Prostatic Hyperplasia

I-PSS and QOL Scores

How often do you experience Never <1 in 5 <½ the About = ½ >½ the Almost
the following symptoms? Times Time the Time Time always
There are 7 evaluated
Over the past month or so, how often 0 1 2 3 4 5 items.
have you had a sensation of not emptying
your bladder completely after you finished The severity is evaluated
urinating? by the total score

Over the past month or so, how often 0 1 2 3 4 5

have you had to urinate again less than
two hours after you finished urinating? Score 0 - 7: mild

Score 8 - 19: moderate

Over the past month or so, how often 0 1 2 3 4 5
have you found you stopped and started Score 20 - 35: severe
several times when you urinated?

Over the past month or so, how often 0 1 2 3 4 5

have you found it difficult to postpone urination?

Over the past month or so, how often have 0 1 2 3 4 5

you had a weak urinary stream?

Over the past month or so, how often have 0 1 2 3 4 5

you had to push or strain to begin urination?

Over the past month or so, how many times 0 1 2 3 4 >5

did you most typically get up to urinate from the
time you went to bed at night until the time you 0 1 2 3 4 5
got up in the morning?
QOL Score
Very Satisfied Mostly So so Somewhat Dissatisfied Very Since the quality of life
satisfied satisfied dissatisfied dissatisfied of each patient varies, it
How satisfied would you feel if your bladder 0 1 2 3 4 5 6 is absolutely necessary
problem were to continue unchanged? to evaluate QOL scores

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Benign Prostatic Hyperplasia
Recommended Therapeutics
The following index lists therapeutic classifications as recommended by the treatment guideline. For the prescriber's
reference, available drugs are listed under each therapeutic class. For drug information, please refer to the Philippine
Drug Directory System (PPD, PPDr, PPD Text, PPD Tabs).

5-Alpha Reductase Inhibitors

Dutasteride
Avodart

Finasteride
Proscar

Alpha-Adrenergic Blockers

Alfuzosin
Xatral
Xatral OD

Doxazosin
Alfadil XL

Tamsulosin

Terazosin
Conmy
Hykor
Hytrin

Estrol Fraction Binders

Mepartricin
Ipertrofan

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