Clinical Evidence Concise
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Benign Prostatic Hyperplasia
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Am Fam Physician. 2004 Oct 1;70(7):1325-1326.
This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The practice recommendations in this activity are available at http://www.clinicalevidence.com/ceweb/conditions/msh/1801/1801.jsp.
What are the effects of treatment?
Systematic reviews have found that alpha blockers improve lower urinary tract symptom scores compared with placebo. Systematic reviews found limited evidence that different alpha blockers have similar effects. Randomized controlled trials (RCTs) found limited evidence that alpha blockers improved symptom scores compared with the 5-alpha reductase inhibitor finasteride. One RCT found no significant difference between tamsulosin and saw palmetto plant extracts in symptom scores or maximum flow rate after one year. Another RCT found limited evidence suggesting that alpha blockers were less effective than transurethral microwave thermotherapy in improving symptoms over 18 months. We found no RCTs comparing alpha blockers with surgical treatment.
5-Alpha Reductase Inhibitors.
One systematic review and additional RCTs have found that 5-alpha reductase inhibitors improve symptom scores and reduce complications compared with placebo. The review found that 5-alpha reductase inhibitors were associated with more adverse events than placebo, including decreased libido, impotence, and ejaculatory dysfunction. RCTs found limited evidence that the 5-alpha reductase inhibitor finasteride was less effective at improving symptom scores than alpha blockers. One systematic review found no significant difference in symptom scores between finasteride and saw palmetto plant extracts. We found no RCTs comparing 5-alpha reductase inhibitors with surgical treatment.
Saw Palmetto Plant Extracts
One systematic review has found that saw palmetto plant extracts improve symptom scores compared with placebo. It found no significant difference in symptom scores between saw palmetto plant extracts and the alpha blocker tamsulosin or the 5-alpha reductase inhibitor finasteride. One RCT found no significant difference in symptom scores between tamsulosin and tamsulosin plus saw palmetto plant extracts.
Transurethral Microwave Thermotherapy
RCTs found that transurethral microwave thermotherapy reduced symptom scores compared with sham treatment. We found limited evidence that thermotherapy was less effective in relieving short-term symptoms than transurethral resection. One RCT found that transurethral microwave thermotherapy improved symptom scores over 18 months compared with alpha blockers.
Transurethral Resection Versus No Surgery
RCTs found that transurethral resection reduced symptom scores more than watchful waiting and did not increase the risk of erectile dysfunction or incontinence.
LIKELY TO BE BENEFICIAL
Beta-Sitosterol Plant Extract
One systematic review has found that beta-sitosterol plant extract improves lower urinary tract symptom scores compared with placebo in the short term. We found no RCTs comparing beta-sitosterol plant extract with other treatments.
One systematic review found limited evidence that P. africanum increased peak urinary flow and reduced residual urine volume at four to 16 weeks compared with placebo. We found no RCTs comparing P. africanum versus other treatments.
Rye Grass Pollen Extract
One systematic review found limited evidence that rye grass pollen extract increased self-rated improvement and reduced nocturia at 12 to 24 weeks compared with placebo. However, the review identified only two small RCTs, from which we were unable to draw reliable conclusions. We found no RCTs comparing rye grass pollen extract with other treatments.
Transurethral Resection Versus Less Invasive Surgical Techniques
RCTs found no significant difference in symptom scores between transurethral resection and transurethral incision or between transurethral resection and electrical vaporization. RCTs found limited evidence that transurethral resection improved symptom scores more than visual laser ablation but that transurethral resection may be associated with a higher risk of blood transfusion.
Transurethral Resection Versus Transurethral Needle Ablation
One RCT found that transurethral resection reduced symptom scores compared with transurethral needle ablation after one year, although transurethral needle ablation caused fewer adverse effects.
Benign prostatic hyperplasia is defined histologically. Clinically, it is characterized by lower urinary tract symptoms (urinary frequency, urgency, a weak and intermittent stream, needing to strain, a sense of incomplete emptying, and nocturia) and can lead to complications, including acute urinary retention.
Estimates of the prevalence of symptomatic benign prostatic hyperplasia range from 10 to 30 percent for men in their early 70s, depending on how benign prostatic hyperplasia is defined.1
The mechanisms by which benign prostatic hyperplasia causes symptoms and complications are unclear, although bladder outlet obstruction is an important factor.2 The best documented risk factors are increasing age and normal testicular function.3
Community- and practice-based studies suggest that men with lower urinary tract symptoms can expect slow progression of the symptoms.4,5 However, symptoms can wax and wane without treatment. In men with symptoms of benign prostatic hyperplasia, rates of acute urinary retention range from 1 to 2 percent a year.5–7
Robyn Webber has been reimbursed by MSD, manufacturers of finasteride, for attending several conferences.
The authors acknowledge previous contributors of this chapter: Michael Barry and Claus Roehrborn.
search date: July 2003
editor’s note: Tamsulosin is called Flomax in the United States.
Adapted with permission from Webber R. Benign prostatic hyperplasia. Clin Evid Concise 2004;11:218–9.
1. Bosch JL, Hop WC, Kirkels WJ, et al. Natural history of benign prostatic hyperplasia: appropriate case definition and estimation of its prevalence in the community. Urology. 1995;46(suppl A)34–40.
2. Barry MJ, Adolfsson J, Batista JE, et al. Committee 6: measuring the symptoms and health impact of benign prostatic hyperplasia and its treatments. In: Denis L, Griffiths K, Khoury S, et al., eds. Fourth International Consultation on BPH, Proceedings. Plymouth, UK: Health Publication Ltd., 1998:265–321.
3. Oishi K, Boyle P, Barry MJ, et al Committee 1: Epidemiology and natural history of benign prostatic hyperplasia. In: Denis L, Griffiths K, Khoury S, et al., eds. Fourth International Consultation on BPH, Proceedings. Plymouth, UK: Health Publication Ltd., 1998:23–59.
4. Jacobsen SJ, Girman CJ, Guess HA, et al. Natural history of prostatism: longitudinal changes in voiding symptoms in community dwelling men. J Urol. 1996;155:595–600.
5. Barry MJ, Fowler FJ, Bin L, et al. The natural history of patients with benign prostatic hyperplasia as diagnosed by North American urologists. J Urol. 1997;157:10–5.
6. Jacobsen S, Jacobson D, Girman C, et al. Natural history of prostatism: risk factors for acute urinary retention. J Urol. 1997;158:481–7.
7. McConnell J, Bruskewitz R, Walsh P, et al. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. N Engl J Med. 1998;338:557–63.
This is one in a series of chapters excerpted from Clinical Evidence Concise, published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom. Clinical Evidence Concise is published in print twice a year and is updated monthly online. Each topic is revised every eight months, and subscribers should view the most up-to-date version at http://www.clinicalevidence.com. If you are interested in contributing to Clinical Evidence, please contact Klara Brunnhuber (firstname.lastname@example.org). This series is part of the AFP’s CME. See “Clinical Quiz” on page 1213.
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