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Overview: Medical treatment of lower urinary tract symptoms secondary to BPH

AMA Therapeutic Insights newsletter – September 2008

Access full programAMA Therapeutic Insights is a free, online CME program featuring the latest treatment guidelines and prescribing data for specific disease states. This is an overview of the September 2008 newsletter, "Medical treatment of lower urinary tract symptoms secondary to BPH"

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Benign prostatic hyperplasia (BPH) is a common problem in older men. BPH is characterized by the nonmalignant overgrowth of prostatic tissue surrounding the urethra, ultimately constricting the urethral opening and commonly giving rise to associated lower urinary tract symptoms (LUTS) such as urgency, frequency, nocturia, incomplete bladder emptying, and weak urine stream. It is estimated that 50 percent of men with histopathologic BPH have moderate to severe LUTS. Left untreated, serious complications can occur in men with BPH including acute urinary retention (AUR), renal insufficiency and failure, urinary tract infection, and bladder stones.

How does the medical treatment of LUTS in men change with increasing age?
Figure 1
In men with symptoms that become bothersome, medications are commonly recommended. The tendency to use medical therapies for LUTS increases with patient age and is supported by the patient claims data. While only 19 percent of men aged 45-54 diagnosed with BPH are receiving some form of medical treatment (ie, drug treatment), the percentage of those over 65 years of age treated increases to 43 percent (Figure 1).

Which BPH medications are being used by physicians to treat LUTS secondary to BPH?
Figure 2The medications used to treat LUTS related to BPH fall into two classes of agents: alpha 1-blockers and 5-alpha reductase inhibitors. These agents are used either alone or in combination. Anticholinergic/anti-muscarinic medications (eg, tolterodine, flavoxate, and oxybutynin) which are widely used to treat symptoms of overactive bladder in women are also being used to treat those aspects of LUTS in BPH patients that include frequency, urgency, and incontinence. Figure 2 provides a comparison on the use of the different classes of agents in men with diagnosed BPH.

Figure 1
The alpha 1-blockers are used in over 80 percent of men over 45 years of age with diagnosed BPH, consistent with the recommendation of the AUA clinical guidelines that they are first line therapy. A further breakdown of the use of individual agents in the treatment of BPH is presented in Figure 3 and gives a more detailed picture of the relative use of alpha 1-blockers. The most commonly used alpha 1-blocker is tamsulosin, which is used in half of patients with BPH. The other three alpha 1-blockers, alfuzosin, doxazosin and terazosin are used much less than tamsulosin, but about equally in patients when compared with each other (13 percent-14 percent). The older agents (ie, doxazocin and terazocin) are now prescribed mostly as generics.

Sample case study from "Medical treatment of lower urinary tract symptoms secondary to BPH"
A 65-year-old male presents with marked LUTS. His symptom score is in the severe range (AUA-SI of 31). His physical examination is noncontributory except for a DRE revealing a prostate of approximately 25 gm. His PSA is 0.4 ng/dL supporting the relatively small prostate gland on examination. The rest of his laboratory studies are noncontributory and his PVR urine was 25 cc. What is your approach?

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CME information for this newsletter