The current approach to the management of benign hypertrophy of the prostate

Epidemiology. The incidence of benign prostatic hyperplasia (BPH) has increased in proportion to the life expectancy and has become the third leading cause of health expenditure in industrialized countries. Eighty per cent of men are treated for benign prostatic hyperplasia during their lifetime. In Europe, the mean age of diagnosis is 65 years. The clinical symptoms are assessed by the IPSS score (International Prostate Symptom Score) and by the maximum flow rate, where frank dysuria is defined as a flow rate of less than 10 ml/sec. Physiology. The prostate contains equal proportions of glandular epithelial structures and fibromuscular connective tissue stroma. The glandular prostate is innervated by cholinergic nerves, while the smooth muscle of the stroma and the urethra are innervated by adrenergic nerves. BPH arises in the transitional zone (fairly glandular). Androgen deprivation (castration, antiandrogens, progestogens, 5-alpha-reductase inhibitors) induces a 30% reduction of the prostatic volume (especially epithelial). BPH could be due to reactivation of the embryonic potential of the stroma. Certain growth factors appear to be involved in BPH. Inflammatory and immunological phenomena may also be involved. Evaluation. Plan of clinical interview, clinical examination and laboratory and radiological data. A 40-year-old man has one chance in 30 of being operated for benign prostatic hyperplasia if he lives to the age of 80. Medical treatments have been developed since 1980 which inhibit the course of BPH and minimize some of the clinical symptoms: plant extracts, alpha-blockers, 5-alpha-reductase inhibitors. Conventional surgical treatments, open prostatectomy and endoscopic resection, have been completed by laser therapy, thermotherapy and cryotherapy.     

Diagnosis and treatment of benign prostatic hyperplasia in general practice. Norwegian Medical Society

The prevalence of benign prostatic hyperplasia increases with increasing age. The growing number of elderly men in the population will cause a marked increase in the number of men suffering from this condition. The magnitude of the problem necessitates close cooperation between urologists and general practitioners in future in order to take care of patients with benign prostatic hyperplasia. The purpose of the present survey is to present guidelines for general practitioners to enable them to diagnose this condition and to present the various alternative treatments currently available. Patients with mild and modest symptoms do not need to be referred to an urologist and can be taken care of by the general practitioners themselves.     

Transperineal prostate needle biopsy guided by transurethral ultrasound in patients without a rectum

OBJECTIVES: Patients with elevated prostate-specific antigen (PSA) and no access to the rectum present a diagnostic challenge to the urologist. This study was undertaken to determine the efficacy of transperineal prostate biopsy using transurethral ultrasound guidance for the detection of prostate cancer. METHODS: Five men status post either total colectomy or abdominoperineal resection (age range: 58 to 73 years, mean age 65.8 years) were referred to us for the evaluation of an elevated PSA (range: 5.6 to 21.4 ng/dL, mean 16.1 ng/dL). Seven procedures were performed utilizing transurethral ultrasound to guide transperineal prostate biopsies in these men. RESULTS: Biopsy results revealed benign prostatic hyperplasia in 4 procedures and prostate cancer in 3 procedures. CONCLUSIONS: Transurethral ultrasound enables the practitioner to perform accurate sonographic assessment and precise biopsy of the prostate in such patients.     

Restricted occurrence of an unusual ganglioside GD1 alpha in rat brain and its possible involvement in dendritic growth of cerebellar Purkinje neurons

The type and magnitude of urinary symptoms, the behavioral adjustments necessitated by such symptoms, and the degree of patient satisfaction with treatment and current health were evaluated in 102 men with symptomatic benign prostatic hyperplasia (BPH) who had been receiving finasteride for 9 to 12 months. We also evaluated these variables in a group of 109 men who had undergone transurethral resection of the prostate (TURP) for symptomatic BPH 9 to 12 months before the study. A validated, patient-directed telephone questionnaire was used to solicit information. Men with BPH who continued to receive finasteride therapy for at least 9 months experienced considerable symptomatic relief during the first year of therapy, and reported a high degree of satisfaction with their urinary condition. Urinary symptoms either resolved or occurred only rarely in the majority of men treated with finasteride. Most of the BPH patients taking finasteride (78%) indicated that urinary symptoms did not restrict their participation in normal activities. Fifty-four percent of finasteride patients rated their current health as excellent or very good, and 87% indicated that their current condition represented an improvement over their pretreatment state. Responses in the men treated with TURP reinforced previous observations about the effectiveness of this treatment in men with symptomatic BPH. Thus in the appropriate patient group, finasteride represents an effective management option for symptomatic BPH.     

The treatment of benign prostatic hyperplasia with alpha blockers in men over the age of 80 years

OBJECTIVE: To determine the safety and efficacy of alpha blockade with doxazosin and terazosin in men over the age of 80 years with symptomatic benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: Thirty-six men (mean age 83.6 years, SD 5.6, range 80-96) received either doxazosin 4 mg (11 men) or 8 mg (10 men), or terazosin 5 mg (five men) or 10 mg (10 men), once daily at night. Twenty-eight men (78%) were on other anti-hypertensive medication; the type and dosage were not changed during the study. Efficacy and safety were assessed using measurements of peak urinary flow rate, symptom scores and the incidence of adverse events. RESULTS: Of the 36 men, 33 (92%) remained on study medication at 6 months; the remaining three (8%) discontinued because of asthenia. After 3 months of treatment, the peak urinary flow rate increased significantly (P < 0.008) for both doxazosin (+3.7 mL/s) and terazosin (+3.2 mL/s). The American Urological Association symptom score improved significantly (P < 0.01) with both alpha blocker after 3 months of treatment and efficacy was maintained at 6 months. There were small, non-significant decreases in blood pressure in patients receiving doxazosin or terazosin, but no differences between patients who were normotensive at baseline and those whose blood pressure was controlled by other anti-hypertensive drugs. CONCLUSION: These results suggest that alpha blockade with either doxazosin or terazosin is well tolerated and effective in older men with symptomatic BPH. Furthermore, patients on concomitant anti-hypertensive medication need no alteration of their therapeutic regimen before the initiation of alpha blockade for BPH.     

A computer program for the support of the treatment-diagnosis process for patients with benign prostatic hyperplasia

The computer program "Prostate" (Windows, 1.0 version) is designed to assist the urologist in: objective assessment of the lower urinary tract in benign prostatic hyperplasia (BPH), accumulation and storage of information on the patients (data file), comparison (text, graphics) with previous data to control the course of the disease, treatment efficacy, to refer to international recommendations and recent advances in the treatment of both BPH and its complications. The status of the lower urinary tract is to be described basing on the IPSS and QOL tables, PSA findings, rhythm of spontaneous uresis, uroflowmetry, residual urine, prostate size, laboratory and microbiological urinalysis. The program "Prostate" is a new step in medical recording and efficacy of BPH treatment assessment in urology.     

A comparison of transurethral resection of the prostate and medical treatment for the patient with moderate symptoms of benign prostatic hyperplasia

Transurethral resection of the prostate is the most common surgical treatment for benign prostatic hyperplasia. We conducted a prospective randomized clinical trial to compare this surgery with medical treatment in men with moderate symptoms of benign prostatic hyperplasia. Of 98 men over the age of 54 years who were screened between June 1993 and June 1995, 53 were studied (25 in the surgery group and 28 in the medication group). Patients' symptoms and the degree to which they were bothered by urinary difficulties were measured with standardized questionnaires and medical evaluations. The men randomly assigned to the surgery group underwent surgery within 2 weeks after the assignment. Surgery was not associated with an impotence or urinary incontinence. The follow-up period was 1 year. Surgery was significantly associated with improvement in residual urinary volume and peak flow rate; and also in the scores for urinary difficulties, sexual performance and interference with activities of daily living (P < 0.001 for all comparisons). We concluded that for patients with moderate symptoms of benign prostatic hyperplasia, surgery is more effective than medication in improving genitourinary symptoms and enhancing the quality of life. Thus, medication as treatment should be reserved for patients who are less bothered by urinary difficulty or who wish to delay surgery.     

A prospective, randomized 1-year clinical trial comparing transurethral needle ablation to transurethral resection of the prostate for the treatment of symptomatic benign prostatic hyperplasia

PURPOSE: We assess the 1-year efficacy and safety of transurethral needle ablation of the prostate compared to transurethral resection of the prostate for the treatment of symptomatic benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: A prospective, randomized clinical trial of 121 men 50 years old or older with symptomatic BPH was performed at 7 medical centers across the United States. Of the men 65 (54%) were treated with transurethral needle ablation of the prostate and 56 (46%) underwent transurethral resection of the prostate. Mean and percentage changes from baseline and between cohorts for American Urological Association (AUA) symptom score, AUA bother score, quality of life score, peak urinary flow rate and post-void residual urine volume were measured at 1, 3, 6 and 12 months following treatment. Length of procedure, hospitalization, type of anesthesia, post-procedure catheterization, side effects and sexual function were compared. RESULTS: Transurethral needle ablation and resection resulted in a statistically significant improvement in AUA symptom, bother and quality of life scores, peak urinary flow rate and post-void residual. At 1-year followup, needle ablation and resection were equally effective in enhancing quality of life. Needle ablation had less effect on sexual function, with resection being associated with a greater incidence of retrograde ejaculation. Needle ablation could be performed as an outpatient procedure with local anesthesia while resection required anesthesia and hospitalization. Needle ablation was associated with markedly fewer side effects than resection. CONCLUSIONS: Compared to transurethral resection of the prostate, transurethral needle ablation of the prostate is an efficacious, minimally invasive treatment for symptomatic BPH that is associated with few side effects.     

Economic public health aspects of benign prostatic hyperplasia in Austria

Benign prostatic hyperplasia (BPH) is one of the most frequent diseases in advanced aged men. The introduction of a new coding system (ICD-VESKA) in 1989 made it possible to analyze the number of hospitalized cases and to calculate the costs of inpatient care. In 1990 10,710 BPH cases were treated within Austrian hospitals. Controlling for multiple entries 9,742 individual patients (269.4 per 100,000) were treated 138,761 days. Case fatality was 0.5% (46 deaths). The number of inpatients comprises only the top 1,3% of morbidity, the total number is estimated with 770,000 patients. Based on the official nursing fees total costs in public affiliated hospitals were AS 250 millions. Including private hospitals total costs increase to AS 306 millions. The inpatient care of BPH represents only a small proportion of the total health and economic burden, which obviously mainly occurs in the outpatient system. Therefore BPH is one of the diseases of which social and economic importance is usually underestimated due to a lack of information.     

Monoclonal antibody FC-5.01, directed against CD63 antigen, is internalized into cytoplasmic vesicles in the IIB-BR-G human breast cancer cell line

PURPOSE: Benign prostatic hyperplasia is common among men who may be candidates for prostate cancer screening using prostate-specific antigen (PSA) testing. Patterns of PSA testing among men with evidence of benign prostatic hyperplasia have not been studied. METHODS: We examined the prevalence and correlates of a self-reported history of PSA testing. In 1994, 33,028 US health professionals without prostate cancer aged 47 to 85 years provided information on prior PSA testing, lower urinary tract symptoms characteristic of benign prostatic hyperplasia, history of prostatectomy, and prostate cancer risk factors. In 1995, a subset of 7,070 men provided additional information on diagnosis and treatment of benign prostatic hyperplasia. RESULTS: From 39% of men in their 50s to 53% of men in their 80s reported PSA testing in the prior year (P <0.0001 for trend with age). Men were more likely to report PSA testing if they had lower urinary tract symptoms characteristic of benign prostatic hyperplasia (age-adjusted odds ratio for severe symptoms 2.2, 95% confidence interval 1.8 to 2.6), a prior history of prostatectomy (age-adjusted odds ratio 1.1, 95% confidence interval 1.02 to 1.2), or a physician diagnosis of benign prostatic hyperplasia (odds ratio 1.9, 95% confidence interval 1.7 to 2.2; adjusted for age, signs or symptoms of benign prostatic hyperplasia, and prostate cancer risk factors). CONCLUSIONS: These US health professionals reported preferential use of PSA testing among men least likely to benefit from early cancer detection (older men) and among men most likely to have a false-positive PSA result (men with benign prostatic hyperplasia). Physician and patient education are needed to promote more rational and selective use of this screening test.     

Ratio of free-to-total prostate specific antigen in serum cannot distinguish patients with prostate cancer from those with chronic inflammation of the prostate

PURPOSE: We demonstrate the effect of chronic inflammation of the prostate on the ratio of free-to-total prostate specific antigen (PSA) in serum calculated as a percentage of free PSA and, therefore, that percentage of free PSA is an unspecific means to distinguish among prostate cancer, chronic prostatitis and benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: Total, free and percentage of free PSA was measured in 66 men with prostate cancer, 119 with BPH and 17 with asymptomatic chronic prostatitis. In all patients the diagnosis was histopathologically confirmed by microscopic examination of prostatic specimens after sextant biopsy, transurethral prostatic resection or prostatectomy. RESULTS: The median values of total, free and percentage of free PSA were 4.11 microg./l., 0.75 microg./l. and 20.4% in patients with BPH, 10.0 microg./l., 0.84 microg./l. and 8.5% in those with prostate cancer, and 7.60 microg./l., 1.23 microg./l. and 10.6% in those with chronic prostatitis. Patients with prostate cancer and chronic prostatitis had a significantly lower percentage of free PSA than those with BPH. Receiver operating characteristics curve analysis showed that percentage of free PSA as a discriminator between prostate cancer and BPH was not suitable for differentiating between prostate cancer and chronic prostatitis. CONCLUSIONS: Chronic prostatitis is not characterized by elevated total PSA concentrations alone but also by a decreased percentage of free PSA, a tendency similar to that in prostate cancer. This unspecific change in percentage of free PSA must be considered to interpret the percentage of free PSA correctly.     

Increased incidence of depressive symptoms in men with erectile dysfunction

OBJECTIVES: To investigate the hypothesis that men with erectile dysfunction (ED) have a higher incidence of depressive symptoms compared with age-matched control subjects. We also hypothesized that depressive symptoms impact on the level of libido and on the success of treatment of ED. METHODS: One hundred twenty men with ED or benign prostatic hyperplasia (BPH) were divided into three groups. Group 1 had ED only, group 2 had BPH only, and group 3 had both ED and BPH. Patients were screened for depressive symptoms using the Primary Care Evaluation of Mental Disorders and the Beck Depression Inventory. They were also surveyed for comorbidity, marital status, severity of ED, level of libido, prior ED treatment choice (if any), success of treatment, and others. RESULTS: One hundred patients completed the questionnaires. Depressive symptoms were reported by 26 (54%) of 48 men with ED alone, 10 (56%) of 18 men with ED and BPH, and 7 (21 %) of 34 men with BPH alone. Patients with ED were 2.6 times more likely to report depressive symptoms than men with BPH alone (P < 0.005). Patients with depressive symptoms reported lower libido than other patients (P < 0.0001). Severity of comorbidities did not differ among the three groups. A total of 33 patients with ED had prior treatment for ED using penile injections or vacuum devices. All 15 (100%) patients with ED only continued treatment and were satisfied with its outcome, whereas only 7 (38.9%) of 18 patients with ED and depressive symptoms continued treatment (P < 0.00021). CONCLUSIONS: ED is associated with high incidence of depressive symptoms, regardless of age, marital status, or comorbidities. Patients with ED have a decreased libido compared with control subjects. In addition, patients with depressive symptoms have a lower libido than patients without depressive symptoms. Patients with ED and depressive symptoms are more likely to discontinue treatment for ED than other patients with ED. These data emphasize the importance of a multidisciplinary approach to the treatment of erectile dysfunction.     

The clinical utility of measuring free-to-total prostate-specific antigen (PSA) ratio and PSA density in differentiating between benign prostatic hyperplasia and prostate cancer

OBJECTIVE: To evaluate the role of free-to-total prostate-specific antigen ratio (f/tPSA), prostate volume and PSA density in differentiating between men with prostate cancer and benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: The study comprised 51 patients who were assessed after transurethral electroresection of the prostate (16 with prostate cancer and 35 with BPH). Patients with a tPSA of < or = 4.0 ng/mL and > or = 30.0 ng/mL were excluded from the analysis. Total and fPSA were measured using an immunoradiometric assay and prostate volume was determined by transrectal ultrasonography. The incidence of prostate cancer and BPH was then compared with the PSA variables to determine specificity and predictive value. RESULTS: Most patients with BPH had a tPSA of 4.0-6.0 ng/mL; no patients with BPH had a tPSA of > 20.0 ng/mL. Most patients with prostate cancer had a f/tPSA of 6-10%. The area under the receiver operating characteristic curve for f/tPSA was significantly greater than that for tPSA (P < 0.003). CONCLUSIONS: The measurement of f/tPSA and PSA density increase the specificity of the differential diagnosis between BPH and prostate cancer.     

The relationship between serum PSA value and the weight of the inner gland of the prostate in the cases of benign prostatic hyperplasia

(BACKGROUND): To study reasons why serum PSA value (Markit-F) elevates in benign prostatic hyperplasia (BPH). (METHODS): The relationship between total prostatic weight and the outer gland weight in 48 cases of BPH undergoing subcapsular prostatectomy was studied by ultrasound measurement. PSA was compared with prostatic weight, inner gland weight, outer gland weight, growth speed of the inner gland and age in the 48 cases. (RESULTS): 1) The weight of the outer gland increased slightly in proportion to the development of BPH. However, the increase was not significant statistically. 2) PSA correlated with the inner gland weight and growing speed of the inner gland well. 3) PSA did not correlate with the outer gland weight and age. (CONCLUSIONS): It is well known that PSA elevates not only in the cases of prostatic cancer but also in the cases of BPH and that PSA correlates with the whole prostatic weight. This study revealed that the elevation of PSA in the cases of BPH was caused by enlargement of the inner gland.     

The predictive value of baseline variables in the treatment of benign prostatic hyperplasia using high-energy transurethral microwave thermotherapy

OBJECTIVE: To evaluate the combination of patient age, prostate size, grade of outlet obstruction and total amount of energy, all independent predictive variables of treatment outcome in patients with lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) treated with high-energy transurethral microwave thermotherapy (HE-TUMT), and thus provide nomograms for predicting treatment outcome after HE-TUMT. PATIENTS AND METHODS: Between October 1993 and July 1996, 247 patients with LUTS and BPH were treated with HE-TUMT using the Prostatron device, software version 2.5 (EDAP Technomed, Lyon, France). The World Health Organisation Response Evaluation Criteria were used to evaluate the outcome. Patient age, prostate volume, total amount of energy and grade of outlet obstruction were categorized using the Akaike information criterion (AIC). The probabilities of a good/intermediate vs a poor response at 26 weeks according to the AIC were calculated. RESULTS: Nomograms are presented providing the estimated probability (95% confidence interval) for a good/intermediate response of the evaluation of the International Prostate Symptom Score at 26 weeks by categories of prostate volume, total amount of TUMT energy and age, and of maximum urinary flow rate by categories of bladder outlet obstruction (linear passive urethral resistance ratio, linPURR) and total amount of energy, and of linPURR by categories of prostate volume and total amount of energy. The total amount of energy appeared to have the most impact in the prediction of good/intermediate and poor response in all three response evaluation criteria. CONCLUSIONS: These nomograms may assist urologists in making clinical recommendations for the treatment of men with LUTS and BPH using HE-TUMT.     

Prostate specific antigen in the expressed prostatic fluid of men with benign prostatic hyperplasia and prostate carcinoma

PURPOSE: We tested the hypothesis that the histochemically demonstrated prostate specific antigen (PSA) content of prostate carcinoma cells does not necessarily reflect PSA production and secretion by evaluating expressed prostatic fluid. MATERIALS AND METHODS: Expressed prostatic fluid and serum from 152 men with clinical benign prostatic hypertrophy (BPH), 132 with histologically proved BPH and 46 with prostate carcinoma were analyzed with the Hybritech PSA assay. RESULTS: Expressed prostatic fluid PSA levels from carcinoma patients (median 1.70 mg./ml., mean 2.25) were significantly higher than in the histologically proved BPH group (median 1.28 mg./ml., mean 1.42, p < 0.05). CONCLUSIONS: PSA concentration is increased in the expressed prostatic fluid of prostates of men with carcinoma compared to those with histological BPH. This finding may be a functional manifestation of a field change or paracrine effects within the prostate.     

Mutation "outbursts" of various genes in natural populations of Drosophila melanogaster

The evaluation and treatment of older men with benign prostatic hyperplasia (BPH) is complicated by the highly variable clinical presentation of men with BPH, which ranges from minor urinary symptoms to acute urinary retention. Treatment choices have expanded with recent advances in medical and surgical therapies. Surgical treatment includes open prostatectomy and transurethral prostatectomy as well as newer technologies that are less invasive and that result in fewer long-term side effects. Response to treatment depends on the patient and should be directed at symptom relief.     

Oxybutynin in the treatment of early detrusor instability after transurethral resection of the prostate

OBJECTIVE: To evaluate the symptomatic and urodynamic effects of oxybutynin in the control of irritative micturitional symptoms during the first week after transurethral resection of benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: Fifty-three patients (median age 67 years, interquartile range 62-72) were included prospectively in a double-blind placebo-controlled study. Pre-operatively, uroflowmetry and cystometrography (CMG) were performed, and the post-void residual volume (PVR) measured; symptoms were rated according to the Boyarski score. CMG was repeated on the first post-operative day and medication was started on the third day. Before withdrawing the catheter on the fifth day. CMG was repeated. Three days later, symptoms were evaluated according to the Boyarski score and uroflowmetry and the estimate of PVR reassessed. RESULTS: In comparison with placebo, oxybutynin significantly decreased frequency, urgency and detrusor pressure at first sensation of filling. However, oxybutynin did not lower the rate of pre-operative detrusor instability and exerted no effect on the maximal capacity of the bladder and corresponding detrusor pressure. Dryness of mouth was reported in 13% and 65% of patients receiving placebo and oxybutynin, respectively. CONCLUSION: Oxybutynin alleviates early irritative symptoms after transurethral resection of BPH, without consistently modifying bladder urodynamics.     

Transurethral enzyme injection--future management of benign prostatic hyperplasia

Although benign prostatic hyperplasia, a common condition among elderly men, has been effectively treated with transurethral resection of the prostate, this surgical procedure is associated with many well-recognized risks and complications. Because of this potential morbidity and mortality, various alternative treatment strategies for benign prostatic hyperplasia have been proposed. The use of enzyme solubilization and ablation of prostatic tissue to alleviate urinary outlet obstruction has proved effective in dogs and warrants investigation in human trials. Transurethral enzyme injection of the prostate has the potential for being a treatment modality with minimal invasiveness, limited requirements for anesthesia, and minimal associated toxicity for the management of benign prostatic hyperplasia.     

Cholestasis assessment by activity of antioxidant enzymes and composition of plasma lipoproteins in patients with liver diseases]

23 patients with benign prostatic hyperplasia (BPH) aged 60-82 years underwent transurethral resection (TUR) of the prostate in different periods after thermal treatment which had appeared uneffective or brought complications. In the performance of the endoscopic techniques we found macroscopic changes of the prostatic parts of the urethra and bladder cervix characteristic for certain thermal impact (energy, power, site of exposure). Intraoperative bleeding of prostatic tissue was also different depending primarily on the time which had passed after the thermal treatment. Minimal bleeding occurred at least 3 months after the thermotherapy. Thus, thermal treatment of the prostate can be used in combined treatment of BPH for reducing intra- and postoperative hemorrhage due to subsequent TUR. Among the methods of thermal therapy, transurethral microwave thermotherapy is preferable as minimally invasive and deeply penetrating into the depth of the prostatic gland with maximal effect. TUR of the prostate should be performed not earlier than 3 months after thermotherapy which is indicated only for patients at high risk of intraoperative hemorrhage because of unaffected circulation. Therefore, it is desirable to include transrectal dopplerography of the prostate to urological examination of BPH patients.