Editorials

Managing BPH: When to Consider Surgery

DREW KEISTER, MD, and RANDALL NEAL, MD
Ehrling Bergquist Clinic, Family Medicine
Residency, Offutt Air Force Base, Nebraska

See related article on page 1403.

In this issue of American Family Physician, Dr. Edwards presents an excellent overview of the management options for benign prostatic hyperplasia (BPH).1 Family physicians commonly counsel patients on surgical options when symptoms do not resolve with medical therapy. Clearly, surgical intervention is necessary in patients with urinary retention or recurrent urinary tract infections; however, the decision is not as clear in other patients. Dr. Edwards accurately reviews the effectiveness of BPH management options. It is also essential that family physicians understand the inherent risks of each option.

Medical therapy for BPH has several risks (Table 1).2 Combination therapy with alpha blockers and 5-alpha reductase inhibitors is an option when monotherapy fails. In one trial, the risk of adverse reactions with combination therapy (terazosin [Hytrin] and finasteride [Proscar]) was similar to the baseline risk with each drug alone.3 The exception was ejaculatory abnormalities, which were reported at a rate of 7 percent in the combination therapy group compared with up to 2 percent in the other groups. During the one-year trial, approximately 8 percent of patients discontinued combination therapy because of adverse reactions, which was comparable with discontinuation rates in the alpha-blocker group. Adverse reactions in patients taking selective alpha blockers with 5-alpha reductase inhibitors are undocumented.3

Transurethral resection of the prostate (TURP) is the standard to which other surgical procedures are compared. However, several alternatives have emerged (Table 2).4-11 The rate of erectile dysfunction in patients undergoing TURP is difficult to interpret. Although some studies report a rate of up to 70 percent,6 the only high-quality study found no significant difference between TURP and watchful waiting.4 This finding raises the important point that some patients develop erectile dysfunction even without surgery. However, interpretation of the results is complicated by the heterogeneous methods of assessing erectile function.

Although standardized scores of erectile function are convenient for statistical purposes, they may not accurately convey the patient-oriented experience of postoperative treatment. The best evidence supports transurethral needle ablation and transurethral incision of the prostate over TURP for erectile dysfunction prevention.8-11

Although medical therapy generally should be initiated before considering surgical therapy, the benefits must be balanced against adverse reaction profiles. Combination therapy is reasonable in patients who do not respond to monotherapy; however, the additional risk of adverse reactions deters many patients. TURP is the most effective technique for reducing the risk of reoperation and urinary symptoms, although several alternative procedures achieve similar short-term relief with fewer complications.

Patients considering surgery should be reminded that the adverse effects of medications are generally reversible after discontinuation of therapy (e.g., dizziness, fatigue, erectile dysfunction), whereas many surgical complications are irreversible (e.g., erectile dysfunction, retrograde ejaculation). As Dr. Edwards states, the therapeutic decision should depend on the individual patient's history, surgical risks, and willingness to tolerate specific adverse effects and complications.

Address correspondence to Drew Keister, MD, at drew.keister@offutt.af.mil. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

1. Edwards JL. Diagnosis and management of benign prostatic hyperplasia. Am Fam Physician. 2008;77(10):1403-1410, 1413.

2. Sanborn KD, LaGow B. Physicians' Desk Reference. 61st ed. Montvale, N.J.: Thomson PDR; 2007:471, 850, 2067.

3. Lepor H, Williford WO, Barry MJ, et al., for the Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group. The efficacy of terazosin, finasteride, or both in benign prostatic hyperplasia. N Engl J Med. 1996;335(8):533-539.

4. Wasson JH, Reda DJ, Bruskewitz RC, Elinson J, Keller AM, Henderson WG, for the Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. N Engl J Med. 1995;332(2):75-79.

5. Hoffman RM, MacDonald R, Monga M, Wilt TJ. Transurethral microwave thermotherapy vs transurethral resection for treating benign prostatic hyperplasia: a systematic review. BJU Int. 2004;94(7):1031-1036.

6. Poulakis V, Ferakis N, Witzsch U, de Vries R, Becht E. Erectile dysfunction after transurethral prostatectomy for lower urinary tract symptoms: results from a center with over 500 patients. Asian J Androl. 2006;8(1):69-74.

7. Shabbir M, Kirby RS. Fact or fiction: what do the benign prostatic hyperplasia data tell us? Curr Urol Rep. 2005;6(4):243-250.

8. Hoffman RM, MacDonald R, Wilt TJ. Laser prostatectomy for benign prostatic obstruction. Cochrane Database Syst Rev. 2004;(1):CD001987.

9. Poulakis V, Dahm P, Witzsch U, Sutton AJ, Becht E. Transurethral electrovaporization vs transurethral resection for symptomatic prostatic obstruction: a meta-analysis. BJU Int. 2004;94(1):89-95.

10. Bouza C, López T, Magro A, Navalpotro L, Amate JM. Systematic review and meta-analysis of transurethral needle ablation in symptomatic benign prostatic hyperplasia. BMC Urol. 2006;6:14.

11. Tkocz M, Prajsner A. Comparison of long-term results of transurethral incision of the prostate with transurethral resection of the prostate, in patients with benign prostatic hypertrophy. Neurourol Urodyn. 2002;21(2):112-116.