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Managing Benign Prostatic Hyperplasia - Article
ABSTRACT: Medical and surgical options for the treatment of benign prostatic hyperplasia have expanded in recent years. Saw palmetto, the most widely used complementary medication, is less effective than standard medical therapy but has fewer side effects. Although non-selective alpha blockers provide rapid relief of symptoms and are relatively inexpensive, they can cause dizziness and orthostatic hypotension. These effects occur less often with tamsulosin, a more selective alpha blocker. Finasteride, a 5alpha-reductase inhibitor, slowly reduces prostatic volume but is not as effective as alpha blockers, especially in men with a smaller prostate. Dutasteride, a new 5alpha-reductase inhibitor, has recently been labeled for the treatment of benign prostatic hyperplasia. Surgery may be appropriate initial treatment in patients with severe symptoms who are not at high risk for complications. Surgery may also be indicated in patients who have failed medical therapy or have recurrent infection, hematuria, or renal insufficiency. Transurethral resection of the prostate is effective in most patients, but it carries some risk of sexual dysfunction, incontinence, and bleeding. Surgical procedures that use thermal microwave or laser energy to reduce hyperplastic prostate tissue have recently become available. In general, the newer procedures are less expensive than transurethral resection of the prostate and have fewer complications; however, the need for retreatment is somewhat greater with these less invasive techniques.
Saw Palmetto for Prostate Disorders - Article
ABSTRACT: Saw palmetto is an herbal product used in the treatment of symptoms related to benign prostatic hyperplasia. The active component is found in the fruit of the American dwarf palm tree. Studies have demonstrated the effectiveness of saw palmetto in reducing symptoms associated with benign prostatic hyperplasia. Saw palmetto appears to have efficacy similar to that of medications like finasteride, but it is better tolerated and less expensive. There are no known drug interactions with saw palmetto, and reported side effects are minor and rare. No data on its long-term usage are available. The herbal product also has been used to treat chronic prostatitis, but currently there is no evidence of its efficacy.
ABSTRACT: Benign prostatic hyperplasia is a common condition affecting older men. Typical presenting symptoms include urinary hesitancy, weak stream, nocturia, incontinence, and recurrent urinary tract infections. Acute urinary retention, which requires urgent bladder catheterization, is relatively uncommon. Irreversible renal damage is rare. The initial evaluation should assess the frequency and severity of symptoms and the impact of symptoms on the patient's quality of life. The American Urological Association Symptom Index is a validated instrument for the objective assessment of symptom severity. The initial evaluation should also include a digital rectal examination and urinalysis. Men with hematuria should be evaluated for bladder cancer. A palpable nodule or induration of the prostate requires referral for assessment to rule out prostate cancer. For men with mild symptoms, watchful waiting with annual reassessment is appropriate. Over the past decade, numerous medical and surgical interventions have been shown to be effective in relieving symptoms of benign prostatic hyperplasia. Alpha blockers improve symptoms relatively quickly. Although 5-alpha reductase inhibitors have a slower onset of action, they may decrease prostate size and alter the disease course. Limited evidence shows that the herbal agents saw palmetto extract, rye grass pollen extract, and pygeum relieve symptoms. Transurethral resection of the prostate often provides permanent relief. Newer laser-based surgical techniques have comparable effectiveness to transurethral resection up to two years after surgery with lower perioperative morbidity. Various outpatient surgical techniques are associated with reduced morbidity, but symptom relief may be less durable.
Medical Treatment of Benign Prostatic Hyperplasia - FPIN's Clinical Inquiries
Managing BPH: When to Consider Surgery - Editorials
ABSTRACT: Hematospermia can be a distressing symptom for patients, but most cases are effectively managed by a primary care physician. Although the condition is usually benign, significant underlying pathology must be excluded by history, physical examination, laboratory evaluation, and, in select cases, other diagnostic modalities. In men younger than 40 years without risk factors (e.g., history of cancer, known urogenital malformation, bleeding disorders) and in men with no associated symptoms, hematospermia is often self-limited and requires no further evaluation or treatment other than patient reassurance. Many cases are attributable to sexually transmitted infections or other urogenital infections in men younger than 40 years who present with hematospermia associated with lower urinary tract symptoms. Workup in these patients can be limited to urinalysis and testing for sexually transmitted infections, with treatment as indicated. In men 40 years and older, iatrogenic hematospermia from urogenital instrumentation or prostate biopsy is the most common cause of blood in the semen. However, recurrent or persistent hematospermia or associated symptoms (e.g., fever, chills, weight loss, bone pain) should prompt further investigation, starting with a prostate examination and prostate-specific antigen testing to evaluate for prostate cancer. Other etiologies to consider in those 40 years and older include genitourinary infections, inflammations, vascular malformations, stones, tumors, and systemic disorders that increase bleeding risk.
Benign Prostatic Hyperplasia and Male Lower Urinary Tract Symptoms - Clinical Evidence Handbook
ABSTRACT: Although routine screening for bladder cancer is not recommended, microscopic hematuria is often incidentally discovered by primary care physicians. The American Urological Association has published an updated guideline for the management of asymptomatic microscopic hematuria, which is defined as the presence of three or more red blood cells per high-power field visible in a properly collected urine specimen without evidence of infection. The most common causes of microscopic hematuria are urinary tract infection, benign prostatic hyperplasia, and urinary calculi. However, up to 5% of patients with asymptomatic microscopic hematuria are found to have a urinary tract malignancy. The risk of urologic malignancy is increased in men, persons older than 35 years, and persons with a history of smoking. Microscopic hematuria in the setting of urinary tract infection should resolve after appropriate antibiotic treatment; persistence of hematuria warrants a diagnostic workup. Dysmorphic red blood cells, cellular casts, proteinuria, elevated creatinine levels, or hypertension in the presence of microscopic hematuria should prompt concurrent nephrologic and urologic referral. The upper urinary tract is best evaluated with multiphasic computed tomography urography, which identifies hydronephrosis, urinary calculi, and renal and ureteral lesions. The lower urinary tract is best evaluated with cystoscopy for urethral stricture disease, benign prostatic hyperplasia, and bladder masses. Voided urine cytology is no longer recommended as part of the routine evaluation of asymptomatic microscopic hematuria, unless there are risk factors for malignancy. (Am Fam Physician. 2013;88(11):747-754.