Lower urinary tract symptoms affect more than half of older men. Options for bothersome symptoms include α- adrenergic-receptor blockers, 5α-reductase inhibitors, phosphodiesterase-5 inhibitor therapy, and antimuscarinic therapy. Read the latest Clinical Practice article on this topic. BPH, a histologic diagnosis, is a condition that occurs with aging; the prevalence increases from 25% among men 40 to 49 years of age to more than 80% among men 70 to 79 years of age.

Clinical Pearls

• What are the lower urinary tract symptoms associated with BPH?

The symptoms are classified as obstructive voiding or bladder storage symptoms. Obstructive voiding symptoms include urinary hesitancy, delay in initiating micturition, intermittency, involuntary interruption of voiding, weak urinary stream, straining to void, a sensation of incomplete emptying, and terminal dribbling. Storage symptoms include urinary frequency, nocturia, urgency, incontinence, and bladder pain or dysuria.

• What are the risk factors for developing BPH?

In addition to increased age, additional risk factors include black (vs. white) race, obesity, diabetes, high levels of alcohol consumption, and physical inactivity; mechanisms underlying these associations remain poorly understood. Physiological markers associated with an increased risk of benign prostatic hyperplasia include levels of endogenous testosterone and dihydrotestosterone as well as increased levels of dehydroepiandrosterone and estradiol, insulin-like growth factors, and inflammatory markers (e.g., C-reactive protein).

Morning Report Questions

Q: What office evaluation should be performed when a diagnosis of BPH is being considered?

A: Evaluation includes a complete history to rule out alternative causes of lower urinary tract symptoms, including consideration of excess fluid and caffeine intake and the use of diuretics or medications with antihistaminic effects that may weaken bladder detrusor function. A digital examination of the prostate should be performed and a PSA measurement obtained. A urinalysis should be ordered to screen for urinary tract infection and to look for hematuria, which might indicate urolithiasis or cancer of the kidney, bladder, or prostate. Urinary tract infections should be treated. Evaluation should also include the use of the American Urological Association Symptom Index, a quantitative measure of the severity of lower urinary tract symptoms. If the patient reports a sense of incomplete bladder emptying or has a palpable bladder on abdominal examination, a post-voiding residual urine measurement should be obtained to rule out “silent” urinary retention (normal residual urine volume, <100 ml).

Q: How does one approach the treatment of BPH?

A: A reasonable approach would be to initiate an alpha-blocker (doxazosin), and then to increase the dose based on symptom response. If symptoms are still bothersome, a 5(alpha)-reductase inhibitor can be added as long as the PSA level is higher than 1.5 ng per milliliter (indicating prostatic enlargement). Another option, particularly if the patient also has erectile dysfunction for which he desires treatment, would be to prescribe a phosphodiesterase-5 inhibitor (currently only tadalafil is approved for these symptoms), since this agent could address both problems. In a randomized, placebo-controlled trial comparing doxazosin, a 5(alpha)-reductase inhibitor (finasteride), and the combination of the two, type 15(alpha)-reductase inhibitors (with or without alpha-blocker therapy), but not alpha-blocker therapy alone, significantly reduced rates of secondary outcomes of urinary retention and the need for invasive therapy for BPH.

Source: NEJM.