Reviews for Primary Care - Fall 2007 - (Page 2) Alpha Blockers for BPH Treatment continued As men age, the caliber of the urinary stream diminishes.3 The diminution of the urinary stream was assumed to be attributable to bladder outlet obstruction (BOO) arising directly from the BPE.4 It was also assumed that BOO resulted in bladder dysfunction leading to lower urinary tract symptoms (LUTS), impaired bladder emptying (post void residual urine), and urinary tract infection. In the most severe and relatively rare cases of benign prostatic enlargement, acute urinary retention, urosepsis, chronic renal insufficiency, and death developed secondary to BPH. Hematuria may also be attributed to BPH, but only as a diagnosis of exclusion. Therefore, the clinical manifestations attributed to BPH include LUTS, incomplete bladder emptying, urinary tract infection, acute and chronic urinary retention, urosepsis, chronic renal insufficiency, and hematuria (Table 1).5 The indications for treating BPH include reversing existing signs and symptoms of the disease or preventing the progression of the disease (Table 2). In the Medical Therapy of Prostatatic Symptoms (MTOPS) trial, only 14% of men with BPH developed symptom progression, 2% developed acute urinary retention, and 1% each developed incontinence or urinary tract infection/urosepsis over a follow-up interval of 4 years.6 Therefore, the indication that most commonly drives the need for intervention is the relief of LUTS with the intent of improving quality of life. The combination arm (alpha blocker plus 5-alpha reductase inhibitor) in the MTOPS trial achieved the greatest risk reduction for BPH progression.6 Men with larger prostates in the MTOPS trial were at greatest risk for developing acute urinary retention.7 Therefore, in men with “large” prostates, combination therapy may be recommended as the most effective regimen to treat LUTS and prevent BPH progression. Interestingly, in a recent randomized, placebo-controlled symptoms. The storage and voiding symptoms are best captured and quantified using self-administered symptom questionnaires that assess the individual patient's symptoms. The American Urological Association Symptoms Index (AUASI) and the International Prostate Symptom Index Score (IPSS) are the most widely used instruments to capture severity of LUTS.9 Both instruments capture 7 symptoms: emptying the bladder, urinary frequency, interrupted urinary stream, postponing of urination, weak stream, straining to initiate urination, and nocturia. The total score for both ranges between 0 and 35. Scores of 0-7, 8-18, and 19 respectively The indication that most commonly drives the need for intervention is the relief of LUTS with the intent of improving quality of life. study of 1522 men at high risk for BPH progression (PSA levels between 1.4-10.0 g/dL, prostate volume 30 cm3, IPSS 13, and PVR 350 mL) the alpha blocker alfuzosin alone was also very effective at preventing BPH progression.8 designate mild, moderate, and severe symptoms.10 The IPSS has an additional question that assesses quality of life and is scored separately on a scale of 0 to 6, with 6 representing the poorest quality. Assessment of Lower Urinary Tract Symptoms LUTS includes urinary storage (irritative) and voiding (obstructive) Pathophysiology of Lower Urinary Tract Symptoms A fundamental question is whether severity of LUTS depends on prostate size. Several studies have demonstrated only a weak correlation between the 2, whether in men diagnosed with BPH11 or men in the general community over the age of 50 years.12 It is therefore not surprising that 5 alpha reductase inhibitors, which reduce prostate volume, have virtually no benefit at relieving LUTS in men with BPH.13 The classes of drugs that relieve LUTS include the alpha blockers,14 phosphodiesterase inhibitors,15 and anti-cholinergics.16 None of these drugs has any impact on prostate volume. The most effective, least costly, and best tolerated of these drugs for relieving LUTS are the Table 1 Clinical Manifestations of Benign Prostatic Hyperplasia • Lower urinary tract symptoms • Incomplete bladder emptying • Urinary tract infections • Acute and chronic urinary retention • Urosepsis • Chronic renal insufficiency • Hematuria Table 2 Indications for Treating Benign Prostatic Hyperplasia • Decreasing LUTS • Eliminating hematuria secondary to BPH • Improving bladder emptying • Reversing acute urinary retention • Preventing LUTS progression • Preventing development of acute urinary retention 2 VOL. 1 NO. 1 2007 REVIEWS FOR PRIMARY CARE
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