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Am Fam Physician. 2008;77(10):1375-1377

See related article on page 1403.

Author disclosure: Nothing to disclose.

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

TherapyAdverse reactions (% of patients)
Alpha blockersDizziness (19)
Fatigue/malaise (12)
Edema (2.7)
Dyspnea (2.6)
Hypotension (1.7)
Selective alpha blockersDizziness (14 to 17)
Retrograde ejaculation (8 to 18)
First-dose orthostasis/syncope (7)
Somnolence (3 to 7)
5-Alpha reductase inhibitorsErectile dysfunction (1 to 10)
Decreased semen production (1 to 10)
Decreased libido (1 to 10)
Gynecomastia (0.1 to 1)
Ejaculation disorders (0.1 to 1)

Transurethral resection of the prostate (TURP) is the standard to which other surgical procedures are compared. However, several alternatives have emerged (Table 2).411 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.811

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.

ProcedureDescriptionShort-term complicationsOccurrence of short-term complicationsRisk of retreatment or resurgeryRisk of sexual dysfunction
TURPRecommended surgical technique because of the extensive data validating its effectivenessUrinary retention or recatheterization4 percent0 to 8 percent6 (most trials show 2 to 5 percent)Erectile dysfunction: 0 to 70 percent (most trials show 10 to 20 percent) 410
Retrograde ejaculation: 57 percent 4,5
TURP syndrome*1 percent
UTI4,5 1 to 13 percent 4,5
Transfusion4,5 1 to 6 percent 4,5
Transurethral incision of the prostateIncision from the urethra to the external capsule in each lobe of the prostate; may be performed under regional anesthesia; only appropriate for prostate size less than 30 mLUrinary retention or recatheterizationReduced incidence of all short-term complications; precise incidence not reported7 Comparable with TURP 7,11 Erectile dysfunction: less than TURP; precise incidence not reported 7
Retrograde ejaculation: comparable with TURP11
TURP syndrome*
UTI (comparable with TURP, trend favors transurethral needle ablation)
Transfusion
Transurethral needle AblationPlacement of radio frequency needles in the prostate to ablate tissueUrinary retention or recatheterizationComparable with TURP, trend favors TURP10 percentErectile dysfunction: 0.3 percent; odds ratio compared with TURP: 0.29 (95% CI, 0.13 to 0.63)10
Retrograde ejaculation: 0.2 percent; odds ratio compared with TURP: 0.03 (95% CI, 0.01 to 0.06)10
TURP syndrome*Not reported
UTIComparable with TURP, trend favors transurethral needle ablation
Transfusion0 percent8
Transurethral Microwave thermotherapyMinimally invasive outpatient treatment; microwave antenna irradiates the prostate to decrease prostate sizeUrinary retention or recatheterization23 percentOdds ratio compared with TURP: 10.05 (P < .001)Erectile dysfunction: 5 percent5
Retrograde ejaculation: 22.2 percent5
TURP syndrome*0 percent5
UTI18 percent5
Transfusion0 percent5
Laser prostatectomyInpatient procedure using a variety of laser techniques to ablate the prostate tissueUrinary retention or recatheterizationSimilar to TURP7 to 20 percent8 Erectile dysfunction and retrograde ejaculation: not significantly different than with TURP8
TURP syndrome*Not reported
UTITwo times more likely than with TURP; P < .05
Transfusion0 percent8
Transurethral Electrovaporization of the prostateEndoscopic electrosurgical equipment is used to destroy prostatic tissue with limited coagulationUrinary retention or recatheterizationPooled difference estimate compared with TURP: 2.89; P = .001Pooled difference estimate compared with TURP: 2.57; P = .0019
Pooled difference estimate favors TURP if greater than 1, favors transurethral electrovaporization if less than 1
Erectile dysfunction and retrograde ejaculation: not significantly different than with TURP8,9
TURP syndrome*Comparable with TURP
UTIComparable with TURP
TransfusionPooled difference estimate compared with TURP: 0.16, P < .0019

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