Benign prostatic hyperplasia: to treat or not to treat?

These abstracts are brief summaries of articles in recent issues of medical journals. Articles selected are of a general nature for the information of practitioners of herbal medicine. A dominant theme is often present throughout the journals which will be reflected in the reviews.

Davidson JH, Chutka DS. 2008. Benign prostatic hyperplasia: treat or wait? J Fam Prac 57:7;454-63.

Benign prostatic hyperplasia (BPH) and its clinical symptoms comprise a major health concern for many older men. Many men fail to seek help despite the fact that the condition may result in decreased quality of life, anxiety and depression. The patient may be uncomfortable broaching the subject for fear that he has cancer or that no effective treatments are available.

Clinicians should routinely talk about urinary function with every male patient over the age of 50. The incidence of BPH increases not only with age but also with other comorbid conditions such as diabetes and erectile dysfunction. The patient should be reassured that BPH is not cancer nor is it a precursor to cancer, and that it is a fairly common, treatable disorder.

Questionnaires such as the International Prostate Symptom Score (IPSS) and the American Urological Association symptom index (AUA-SI) (available on www.auanet.org) can help evaluate symptom severity. Even with high IPSS ratings, watchful waiting may be an option for patients experiencing minimal bother because the risk for progression is relatively small. If this route is chosen patients should be encouraged to minimise alcohol and caffeine use and the intake of fluids in the evening, minimize the use of [alpha]-agonist, anticholinergic, antihistaminic and calcium-channel blocker medications.

With bothersome symptoms, transurethral resection of the prostate (TURP) remains the benchmark for treatment. TURP involves removing a portion of the prostate through the urethra. When compared with watchful waiting, TURP achieved better outcomes with men most bothered by symptoms at the onset. Watchful waiting was also considered safe, but 24% of this group underwent surgery during the 3 year study. There were no increases in urinary incontinence or erectile dysfunction among surgically treated patients.

Transurethral needle ablation (TUNA) and transurethral microwave thermotherapy (TUMT) are treatment choices based on the severity of symptoms. TUNA uses radiofrequency waves into prostatic tissue and is effective over long term, however temporary side effects such as irritative urinary symptoms and urinary retention can occur.

TUMT is the most frequent minimally invasive treatment used worldwide. Heat destroys targeted prostatic tissue while a cooling system protects the prostatic urethra. Its efficacy is high with morbidity related mainly to catheterization for 4-6 weeks. It is an outpatient low risk procedure well suited to high risk patients or those who oppose surgery.

Anne Cowper

PO Box 45, Concord West NSW 2138

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