Benign prostatic hyperplasia: Evaluation and medical management in primary care

Raman Unnikrishnan; Nima Almassi; Khaled Fareed

doi:10.3949/ccjm.84a.16008

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FIGURE 1
The static component of benign prostatic hyperplasia and lower urinary tract symptoms, with hyperplasia leading to urethral compression.
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FIGURE 2
The dynamic component of benign prostatic hyperplasia. The bladder outlet and prostate are richly supplied with alpha-1 receptors (their distribution represented by blue dots), which increase smooth muscle tone, promoting obstruction to the flow of urine. Alpha-1 adrenergic blockers counteract this effect.
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FIGURE 3
An algorithm for diagnosing and managing benign prostatic hyperplasia.

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TABLE 1

Indications for urology referral

Hematuria

Recurrent urinary tract infection

Prior urologic surgery

Elevated prostate-specific antigen

Bladder stone

Abnormal digital rectal examination

Clinical suspicion of a neurologic cause

Urinary retention

History of urinary instrumentation or trauma

Lower urinary tract symptoms refractory to medical management

Desire for urologic evaluation

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TABLE 2

Suggested wholesale price of selected drugs for benign prostatic hypertrophy

Drug class	Drug	Brand name	Dosage form and strength	Package size	Brand name SWP	Generic SWP
Alpha-blockers	Alfuzosin	Uroxatral	10-mg capsules	100 capsules	NA	$421.78
	Doxazosin	Cardura	1-mg tablets	100 tablets	NA	$134.86
	Silodosin	Rapaflo	4-mg capsules(ER)	30 capsules	$249.47	NA
	Tamsulosin	Flomax	0.4-mg capsules (ER)	100 capsules	NA	$421.36
	Terazosin	Hytrin	1-mg capsules	100 capsules	NA	$160.50

5-Alpha reductase inhibitors	Dutasteride	Avodart	0.5-mg capsules	30 capsules	$201.70	$181.53
5-Alpha reductase inhibitors	Finasteride	Proscar	5-mg tablets	100 tablets	$558.65	$313.07

Phosphodiesterase-5 inhibitor	Tadalafil	Cialis	2.5-mg tablets	30 tablets	$281.74	NA

Anticholinergic	Oxybutynin	Ditropan	5-mg tablets	100 tablets	N/A	$76.03

Beta-3 agonist	Mirabegron	Myrbetriq	25-mg tablets (ER)	90 tablets	$1,068.28	NA

ER = extended-release; SWP = suggested wholesale price, as listed in Amerisource Bergen

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TABLE 3

Alpha-blockers for benign prostatic hyperplasia

Drug	Titration required?^a	Dose range (mg)	Difference in peak urinary flow^b (mL/sec)	Difference in IPSS^b
Terazosin^28,29	Yes	2–10	+0.6 to +1.9	−1.0 to −4.0
Doxazosin^30,31	Yes	1–8	+1.4 to +3.5	−2.1 to −4.7
Alfuzosin^32,33	No^c	10	+0.9 to +1.8	−1.0 to −2.0
Tamsulosin^34,35	No	0.4–0.8	+0.6 to +2.6	−1.3 to −3.2
Silodosin³⁶	No	4–8	+0.8 to +1.4	−2.3 to −3.0

↵a Titrated to effect and tolerability.
↵b Compared with placebo.
↵c For extended-release formulation.
IPSS = International Prostate Symptom Score⁸

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TABLE 4

Absolute increase in incidence of the most common adverse effects of alpha-blockers compared with placebo

Adverse effect	Terazosin^28,29	Doxazosin³⁰	Alfuzosin³⁸	Tamsulosin^34,35	Silodosin³⁹
Dizziness	5.9%	15%–20%	2%	5%	0.6–2.1%
Fatigue	4.6%	8%–10%	—	2–3%	—
Peripheral edema	3.1%	—	—	—	—
Orthostatic hypotension	1.4%	8%	0.7%	—	1.1%
Ejaculatory dysfunction	1.2%	—	—	6%–11%	22%–27%

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TABLE 5

Surgical treatments for benign prostatic hyperplasia

	Transurethral resection of prostate (TURP)	Transurethral microwave therapy	Photovaporization of prostate	Simple prostatectomy
Technique description	Endoscopic resection of the prostate under direct visualization using monopolar or bipolar loop electrocautery	Ablation of the prostate using a specialized catheter with a microwave antenna	Endoscopic vaporization of the prostate using high-powered laser energy	Surgical removal of prostatic tissue using an open, laparoscopic, or robotic approach
Anesthesia	Spinal or general	Local	Spinal or general	Spinal or general
Typical postoperative catheterization	24–48 hours (longer if hematuria)	Several days	< 24 hours	Several days
Common complications	Retrograde ejaculation Blood loss anemia Urinary tract infection Urinary retention Bladder neck contracture	Urinary retention Urinary tract infection Retrograde ejaculation	Irritative urinary symptoms Hematuria Urinary tract infection	Hematuria Blood loss anemia Urinary tract infection
Advantages	Gold standard Mean 70% reduction in International Prostate Symptom Score (IPSS) and mean 12-mL/sec improvement in peak urinary flow 1 year after surgery	Office procedure Same-day discharge	Safe to perform while on antiplatelet therapy Can typically remove catheter and discharge home on day of surgery Similar improvement in peak urinary flow and IPSS relative to TURP	Excellent option for men with prostates > 75 g Allows concurrent treatment of bladder diverticula or stones Reduced morbidity with robotic approach Similar improvement in peak urinary flow and IPSS relative to TURP
Disadvantages	Higher risk of hematuria than other surgical options Often requires postoperative hospitalization	Less durable results, high rate of retreatment Less symptom improvement than with other surgical therapies Higher incidence of urinary retention requiring prolonged catheterization Not available in all urology practices	Requires long operative time for large prostate volumes	More invasive procedure with longer convalescence Urologists experienced in this procedure not available in all practices High rate of blood transfusion (lower risk with robotic approach) Requires postoperative hospitalization