Management of Symptomatic BPH in the US: Who Is Treated and How?

Abstract

Objective: To review the contemporary management of symptomatic benign prostatic hyperplasia (BPH) in North America. Methods: Information was obtained from published scientific articles, lay press articles, Medicare outcomes data, IMS market analysis data and surveys among primary care practitioners and urologists. Results: A survey in Olmsted County in the US identified the number of men with an I-PSS score >7 and maximum urinary flow rate <15 ml/s. This survey found that 17% of men in the 50–59 year old age bracket, 27% of men in the 60–69 bracket and 37% of men in the 70–79 bracket meet this minimum criterion for discussions about treatment. Currently in the US, there are approximately 5.6 million men that fall in this category, and the number is expected to double by the year 2025. Primary care physicians in 25% of cases and internal medicine in 24% of cases provide initial management of BPH. Urologists provide initial management in 37% of cases. Improvement in urinary symptoms and quality of life is the most important health outcome in the management of symptomatic BPH in the US, particularly because serious complications from BPH are distinctly uncommon. A survey among urologists determined that for men with mild symptoms, watchful waiting was employed 77% of the time, α₁-adrenoceptor antagonists 21% and finasteride 1%. For those with moderate symptoms and prostate volume ≤40 ml, α₁-adrenoceptor antagonists are employed 88% of the time, finasteride 1% and TURP 1%. When the prostate is in excess of 40 ml, α₁-adrenoceptor antagonists are used 69% of the time, finasteride 10% and TURP 9%. α₁-Adrenoceptor antagonists are also employed most of the time for patients with severe symptoms: 58% of the time for small and 45% of the time for large prostates. The respective data for TURP are 31% and 38%. Primary care physicians utilize predominantly watchful waiting and long-acting α₁-adrenoceptor antagonists. Laser use in the management of BPH has fallen from 40% of urologists in 1994 to 26% in 1997. TUMT and TUNA are each employed by 3% of urologists. The use of transurethral vaporisation of the prostate has increased to 62% of urologists. For those patients being treated with medication, 36% are treated with terazosin, 31% with doxazosin, 15% with finasteride and 18% with tamsulosin, which was introduced only recently and is growing. Conclusions: In the future, the number of older men in the US will increase dramatically. Likely the percentage of patients undergoing surgical treatment such as TURP will decrease but the absolute number having surgery will increase. It is also likely that α₁-adrenoceptor antagonists will be used with greater frequency in the future and finasteride will be used less frequently.