Treatment of benign prostatic hyperplasia

What is benign prostatic hyperplasia and why does it appear?

Benign prostatic hyperplasia ( BPH ) is a benign growth of the prostate associated with age, which usually manifests after 50 years. This growth causes an obstruction in the outflow of urine from the urinary bladder, which is clinically translated into the appearance of lower urinary tract symptoms (LUTS).. Therefore, the concept of BPH should be reserved for patients who meet 3 conditions: they have LUTS, an increase in prostatic size (> 30cc) and are obstructed (have a maximum flow <15 ml / sec).

It is not known exactly how it originates, but there are two factors necessary for the development of BPH: age and the presence of testosterone , because of the hormone-dependent nature of the prostate.

Do all men develop it?

Histological studies indicate that there is no BPH in men under 30 years. The prostate begins to grow after 40 years and continues to grow progressively with age, so that at 90 years, 88% of patients have BPH.

The importance of this pathology, which does not seriously compromise the health of the patient but that alters their quality of life, is that it is the main cause of consultation with the urologist and the second most frequent surgical intervention of the male. This generates a high health cost that is increasing due to the increase in life expectancy .

What symptoms can it cause?

Symptoms of BPH are classified as obstructive or voiding symptoms (weak stream, difficulty in initiating urination , intermittent jet, feeling of incomplete emptying and post-void drip) and irritative or filling symptoms ( frequency , nocturia, urgency and incontinence ). All these symptoms, which are included in the clinical picture known as "prostatism", are not specific to BPH, so the term LUTS is preferred because it is considered more accurate.. In fact, these symptoms can also occur in men with a normal prostate size and in women.

Does it require treatment?

The aim of the treatment is to improve LUTS and, consequently, the quality of life of the patient, in addition to preventing the progression of the disease and the appearance of complications and reducing the need for surgery.. In general, all patients are recommended changes in lifestyle such as avoiding constipation , restricting alcohol consumption, avoiding spicy foods, asparagus, coffee and carbonated beverages, not riding a horse, bicycle or motorbike, have regular sexual activity and not drink liquids at least 2 hours before bedtime. Treatment options include supervised waiting (recommended in patients with mild IPSS ≤ 7 symptoms), pharmacological treatment (predominant option in patients with moderate or severe symptoms) or surgery (when there are complications derived from BPH or no response to the medication).

What pharmacological treatments are recommended?

There are several types of drugs recommended to treat BPH, either alone or in combination: alpha-blockers, 5α-reductase inhibitors, and antimuscarinics. As for phytotherapy or plant extracts, so used in the past, there is no evidence in the literature to support their prescription.

Alpha-blockers (the most commonly used today are Tamsulosin and Silidoxyna) are usually the initial treatment because of their speed of action and good tolerance, although they can cause retrograde ejaculation as a secondary effect and, on the other hand, do not modify the natural evolution of BPH.

The inhibitors of 5αreductase ( Finasteride and Dutasteride ), unlike alpha-blockers, modify long-term the evolution of BPH, so they reduce the risk of acute urinary retention in addition to developing prostate cancer and also the need for surgery. However, they are not exempt from side effects, mainly in the sexual sphere. Its efficacy is not immediate, as it is with alpha-blockers, and is related to the initial size of the prostate, so to be effective they require a minimum prostate volume (generally greater than 40 cc). In any case they are an option for patients with hematuria or recurrent hemospermia secondary to BPH, and we currently have a commercial presentation that associates Tamsulosin and Dutasteride.

Antimuscarinics, alone or associated, are recommended in patients in whom the symptoms of bladder overactive filling predominate, without increasing the incidence of risk of urinary retention. Phosphodiesterase inhibitors, drugs used to treat erectile dysfunction so present in older men, have recently joined the therapeutic arsenal.

In what cases should we resort to surgery and what does it consist of?

Surgery is reserved for patients with BPH complications (infections and repeat hematuria, bladder stones, kidney failure or inability of urinary retention catheter removal) or for those who do not respond to drug therapy.

The standard treatment is transurethral resection of the prostate and for large prostates (greater than 80-100 cc) open surgery or adenomectomy. In recent years, the treatment option with laser technology is becoming a favorable choice since it avoids one of the usual complications of BPH surgery, post-operative bleeding, and decreases the hospital stay, although the cost of the process is greater.