Medical therapy for asymptomatic men with benign prostatic hyperplasia: primum non nocere

Abstract

Medical therapy for benign prostatic hyperplasia (BPH) has become the most widely accepted first-line therapy for symptomatic men with BPH. Alpha-blockade and 5-alpha-reductase inhibitors are safe and effective and have long-term durability. During the past 5 years, an increasing body of evidence has emerged that suggests that medical therapy may also impact on the progression of BPH. Specifically, the Proscar Long-Term Efficacy and Safety (PLESS) and Medical Therapy of Prostate Symptoms (MTOPS) studies have clearly demonstrated that medical therapy can halt various progression parameters, including worsening of symptoms, incidence of urinary retention, and the need for invasive surgery. 1,2 On the basis of these exciting results, some have suggested that even earlier intervention with medical therapy for men at risk of BPH should be considered and, at times, instituted. These suggestions do not seem scientifically, economically, or logistically reasonable. The incidence of BPH is increasing, along with an increasing average life expectancy. Data have suggested that the incidence of histologic BPH is 50% in men who are 60 years old, and as great as 88% in men up to 80 years of age. 3 Clinical BPH, defined as a prostate weight greater than 20 g (as measured by transrectal ultrasonography) in association with symptomatic urinary dysfunction and/or a urinary flow rate less than 15 mL/s, without associated malignancy, has been identified in 1 in 5 men between the ages of 40 and 64 and 2 in 5 men older than 65 years of age. 4 Clearly, BPH impacts significantly on the aging male population. However, it should be emphasized that these estimates are in men with lower urinary tract symptoms. Most of the superb longitudinal data analyzing community-dwelling men with BPH such as the Olmsted County studies have consistently identified men at risk of progression of disease. These include men older than 60 years of age, those who have lower flow rates at baseline (ie, less than 12 mL/s), and have larger prostate volumes (ie, greater than 30 cm 3 ). 5 However, the seminal baseline parameter in distinguishing men at risk of progression is identifiable lower urinary tract symptoms. Asymptomatic men have not been found to be at increased risk. In a more recent analysis of this population, Sarma et al. 6 demonstrated that longitudinal changes in men with lower urinary tract symptoms is highly variable, with an average of 0.3 points per