Treatment of men with minimally symptomatic benign prostatic hyperplasia—PRO: the argument in favor

Abstract

T the 20th century, men with minimally symptomatic benign prostatic hyperplasia (BPH) were generally advised to defer treatment. During most of this period, prostatectomy was the only accepted treatment, and, despite advances in surgical care, observation alone was considered preferable to surgery for men with few symptoms, provided no complications were present. In such cases, treatment deferral has always appeared reasonable, because mild “prostatism” is not bothersome and often seems a normal part of the aging process, progression is usually slow, symptoms often regress spontaneously, and surgical treatment entails the possibility of complications and the likelihood of retrograde ejaculation. However, effective nonoperative treatment for men with BPH has recently become available,3,4 and the “watchful waiting” dogma should now be reevaluated when substantial enlargement of the prostate is discovered. This reasoning is based on an emerging body of knowledge revealing that (a) BPH is a progressive condition in many men, (b) progression of BPH commonly leads to complications that are life-altering, to hospitalization, and to surgery, (c) identification of men at risk of BPH progression is now possible, and (d) well-tolerated medical therapy can help prevent BPH progression and reduce the incidence of acute urinary retention and the need for surgery. Thus, certain men— mainly those with prostate volumes exceeding 30 cm—have become compelling candidates for preventive medical treatment, even though their symptom scores may be low. BPH progression in middle-age men generally involves (a) an increasing prostate gland volume, as much as 2.4 cm/yr,5,6 (b) symptomatic deterioration (International Prostate Symptom Score) in 55%,7 (c) decreasing urinary flow, as much as 4.5%/yr,8 and, ultimately, (d) development of complications and the need for surgery in up to 34% of men.9,10 Such evidence of BPH progression has been found in community-based longitudinal and cross-sectional studies (eg, the Baltimore Longitudinal Study of Aging and the Olmsted County Study) and in the placebo-treated control patients of large randomized trials. The evidence for BPH progression has been qualitatively consistent in a wide variety of studies. The complications from BPH progression include bleeding, infection, stone formation, and acute urinary retention (AUR), the last usually necessitating surgical intervention. In the Olmsted County study, a 60-year-old man with moderate symptoms of BPH had a 10-year average risk for AUR of 13.7%, several times greater than his risk of hip fracture (4.9%), stroke (7.2%), or myocardial infarction (5.1%)11 (Fig. 1). In men with prostate volumes exceeding 30 cm, the risk of AUR is considerably greater than average (see below). Preventive measures are now widely used for hip fracture, stroke, and myocardial infarction. Although AUR is not life-threatening, it is a serious morbid event, usually accompanied by great discomfort, hospitalization, and surgery. Prevention would be desirable. L. S. Marks is a paid consultant to, speaker for, and/or investigator for GlaxoSmithKline, Merck & Company, BeckmanCoulter Inc., Sanofi-Synthelabo, Pfizer, Bayer, Lilly. From the Department of Urology, University of California, Los Angeles, Geffen School of Medicine; and Urological Sciences Research Foundation, Los Angeles, California Reprint requests: Leonard S. Marks, M.D., Urological Sciences Research Foundation, Culver Medical Plaza, 3831 Hughes Avenue, Suite 501, Culver City, CA 90232 Submitted: May 16, 2003, accepted (with revisions): July 14, 2003 EDITORIAL