Benign Prostatic

Hyperplasia
(2011)

Philippine Urological Association, Inc.

3/F, Philippine College of Surgeons Bldg.
992 EDSA, Quezon City
Telephone No.: 454-4439
Telefax No.: 925-6740
E-mail: pua_org@yahoo.com
Website:www.puanet.org.ph
 Benign Prostatic Hyperplasia
Philippine Urological Association, Inc.
3/F, Philippine College of Surgeons Bldg.
992 EDSA, Quezon City
Telephone No.: 454-4439
Telefax No.: 925-6740
E-mail: pua_org@yahoo.com
Website:www.puanet.org.ph

Executive Council 2011

President Jaime C. Balingit, MD
Vice President Raul Winston P. Andutan, MD
Secretary Jose Rufo U. Campaa, MD
Treasurer Ulysses T. Quanico, MD
Auditor Rufino T. Agudera, MD

Council Members Alfredo S. Uy, Jr., MD

Dennis G. Lusaya, MD

Adviser Telesforo E. Gana, Jr., MD

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Benign Prostatic Hyperplasia
Algorithm for the Management of Benign Prostatic Hyperplasia

Benign Medical history to identify OPTIONAL

prostatic other causes of voiding dys-
hyperplasia function/comorbidities that 1. Creatinine
(BPH) may complicate treatment 2. PSA
- for patients with at least a 10- year life expectancy and for whom
Symptom score (Internatio- knowledge of the presence of prostate cancer would change
Men nal Prostate Symptom Score) management
>40 y/o? for all patients as baseline - for whom the PSA measurement may change the management of
guide and evaluation for the patients voiding symptoms
No significant risk Y treatment response
of non-BPH-related 3. Uroflowmetry - specially for patients with a complex medical
origin of lower history and in those desiring invasive therapy, Qmax >15 mL/sec
Physical examination
urinary tract is usual in men between 25 to 60 years old, important in
which includes a focused
symptoms differentiating other causes of obstruction
neurological examination
(LUTS)? 4. Pressure flow studies
and digital rectal exam
5. Ultrasound (to include post-void residual volume)
N Urinalysis as screening 6. Excretory urography - not recommended unless the patient has
(+) Younger age test for pyuria, hematuria, hematuria, UTI, a history of urolithiasis or urinary tract surgery
glocusuria, etc. 7. Cystoscopy
Or (+) concomitant
neurological
diseases Mild symptoms of BPH (AUA symptom score 7)?
Or (+) prior lower Minimal to no bother (symptom score 7)?
urinary tract Minimal to no interference with quality of life
disease or surgery (quality of life score 3)?
No recurrent urinary tract infection?
No recurrent gross hematuria? Y Watchful
No bladder stone? No urinary retention?
More waiting
No renal insufficiency related to BPH?
intensive Peak flow rate >15 cc/sec?
workup Relatively low post-void residual urine?
Patient not bothered by moderate/severe symptoms
(symptoms do not interfere with the daily
activities of living)?
* Alpha adrenergic blockade
therapy - alfuzosin, tamsulosin and N
terazosin are appropriate treatment
options for patients with LUTS
(lower urinary tract symptoms) due Bothersome
to BPH and are believed to have moderate/severe Is watchful Y Watchful
equal effectiveness1 symptoms waiting still waiting
** 5-alpha reductase therapy. indicated?
Finasteride and dutasteride are: (AUA Symptom
- appropriate and effective Score 8)
treatments for patients with LUTS
associated with demonstrable N
prostatic enlargement1 Medical
- indicated for patients with 1. Alpha adrenergic If patient is not
symptomatic prostatic treatment blockade therapy*
enlargement but no bother, to indicated as Y responsive to
2. 5-alpha reductase initial medical
prevent disease progression1 the initial
- not appropriate for patients therapy ** treatment
with LUTS without evidence of therapeutic 3. Combination therapy ***
prostatic enlargement1 modality? (relative surgical
4. Optional treatment indication)
*** Combination therapy -
concomitant use of alpha blocker N (Mepartricin)
and 5-alpha reductase inhibitor
is an appropriate and effective
treatment for patients with LUTS
associated with demonstrable Surgery. The choices of approach
prostatic enlargement (open or endoscopic) and energy source
**** Indications for simple open (electrocautery vs laser) are technical
prostatectomy Is surgical treatment indicated?
- prostate glands larger than decisions based on the patients prostate
E.g., does the patient have:
50 to 75 g, for which TURP size, the individual surgeons judgment and
(transurethral resection of (Absolute indication) the patients comorbidities.
the prostate) is considered
1. Refractory urinary retention?
inappropriate and risky 1. Transurethral resection of the prostate
- large, symptomatic bladder 2. Renal insufficiency due to BPH?
diverticulum 2. Transurethral electrovaporization
3. Bladder stones?
- large, hard bladder stone 3. Transurethral incision of the prostate
4. Bladder diverticulum due to
that cannot be managed 4. Transurethral holmium laser resection/
transurethrally obstruction
Prostatron, Targis, CoreTherm enucleation
5. Recurrent UTI?
and Thermatrx are effective in 5. Transurethral laser vaporization
6. Hematuria refractory to 5-alpha
partially relieving symptoms in 6. Transurethral laser coagulation
men with BPH. Superiority of reductase inhibitor?
one specific device over another (visual laser ablation)
has not been demonstrated in (Relative indication) 7. Open prostatectomy ****
clinical trials to date. Patient request for initial
Transurethral needle ablation Minimally invasive therapy
surgical management?
is effective treatment in partially 1. Transurethral Microwave Heat
relieving symptoms of BPH. Treatment
See the symptom score table after
References. 2. Transurethral Needle Ablation

32

Benign Prostatic Hyperplasia
BACkGROUND
Benign Prostatic Hyperplasia (BPH) is one of the most
common benign disease in men that can lead to prostatic
enlargement, prostatic obstruction and/or lower urinary
tract symptoms. Pathologic changes are found in 88%
of men aged 80 years or older and lower urinary tract
symptoms reported in almost 50% of men aged 50 years
or older in the general population.
The etiology is multi-factorial with age, PSA and prostate
volume being the true factors related to the development
of the disease. A group of patients at increased risk of
progression can be identified based on these specific risk
factors. For those, it might be appropriate to initiate early
treatment. However, for some other patients, surgical
treatment may be the best option.
Recent advances in screening and treatment are now
available for management of patients in the Philippine set-
ting. Clinical practice guidelines of the European Associa-
tion of Urology and the American Urological Association
were reviewed and modified to fit the needs of our local
areas. Though mostly based on scientific evidence from
literature, opinion of the majority of the Committee is given
credibility since these urologists are the ones exposed to
the patients at the grassroots level. Consideration is also
given to the economic and legal factors in doing these
guidelines. Caution is advised in using these guideline
and no physician can be held liable for diverting from the
following protocol. (Lesson 29 Vol 12)
Category 1: Uniform consensus among the members
of the PHC, based on high-level evidence
and experience, that the recommendation
is appropriate
Category 2A: Uniform consensus, based on lower-level
evidence including individual clinical expe-
rience and local practice, that the recom-
mendation is appropriate
Category 2B: Non-uniform consensus (but no major
disagreement), based on lower-level
evidence, that the recommendation is
appropriate
Category 3: Major disagreement that the recommenda-
tion is appropriate
ASSESSMENT OF MEN WITh BPh
The presented recommendations apply only to men
above 40 years of age without significant risk of non-BPH
related origin of LUTS. Men with concomitant neurological
diseases, younger age, prior lower urinary tract disease
or surgery usually require a more intensive work-up not
included here. Accurate and early diagnosis of BPH
Learn to access drug info on your cellphone. Send PPD to 2600 for Globe/Smart/Sun users.
Benign Prostatic Hyperplasia
leads to a better treatment outcome and predetermine
the treatment of choice
Recommended
Medical History to identify other causes of voiding
dysfunction or comorbidities that may complicate
treatment1
Symptom score (International Prostate Symptom
Score) for all patients as baseline guide and evalua-
tion for treatment response1
Physical Examination which includes a focused neu-
rologic examination and digital rectal exam1
Urinalysis used as screening test for pyuria, hematu-
ria, glucosuria, etc.1
Optional
Creatinine1
PSA
- For patients with at least a 10 year life expectancy
and for whom knowledge of the presence of prostate
cancer would change management
- For whom the PSA measurement may change the
management of the patients voiding symptoms
Uroflowmetry - specially for patients with a complex
medical history and in those desiring invasive therapy,
Qmax >15 mL/sec is usual in men between 25 to 60
years old, important in differentiating other causes of
obstruction2b
Pressure flow studies2b
Ultrasound (to include post void residual volume)2a
Excretory urography is not recommended unless the
patient has hematuria, UTI, a history of urolithiasis or
urinary tract surgery2a
Cystoscopy2a
INITIAL MANAGEMENT
Patients with mild symptoms
Watchful waiting is the treatment of choice in patients
with mild symptoms of BPH (AUA Symptom Score <7)
and patients with moderate or severe symptoms who are
not bothered by their symptoms (i.e. do not interfere with
the daily activities of living)1
Patients with moderate to severe symptoms
Treatment options for patients with bothersome mode-
rate to severe symptoms of BPH (AUA Symptom Score
>8) include watchful waiting and the medical, minimally
invasive or surgical therapies1
Explain the benefits and harms of the BPH treatment
options (including watchful waiting) to patients with mode-
rate to severe symptoms (AUA Symptom Score >8) who
are bothered enough to consider therapy.
TREATMENT RECOMMENDATIONS
Watchful Waiting
- indicated for patients with mild or non-bothersome
symptoms1
33
Benign Prostatic Hyperplasia
Medical Treatment
a. Alpha adrenergic blockade therapy
Alfuzosin, tamsulosin and terazosin are appropriate
treatment options for patients with LUTS due to BPH
and are believed to have equal effectiveness1
b. 5-alpha reductase therapy
Finasteride and dutasteride are:
appropriate and effective treatments for patients
with LUTS associated with demonstrable prostatic
enlargement1
indicated for patients with symptomatic prostatic
enlargement but no bother, to prevent disease
progression1
not appropriate for patients with LUTS without
evidence of prostatic enlargement1
c. Combination therapy
Concomitant use of alpha blocker and 5-alpha reduc-
tase inhibitor is an appropriate and effective treatment
for patients with LUTS associated with demonstrable
prostatic enlargement1
d. Optional treatment
Mepartricin2B
Minimally invasive therapy
a. Transurethral Microwave heat Treatment
Prostatron, Targis, CoreTherm and Thermatrx are
effective in partially relieving symptoms in men with
BPH. Superiority of one specific device over another
has not been demonstrated in clinical trials to date
b. Transurethral Needle Ablation
Transurethral needle ablation is effective treatment
in partially relieving symptoms of BPH
Surgery
The patient may appropriately select a surgical inter-
vention as his initial treatment if he has bothersome
symptoms.
Patients who have developed complications of BPH are
best treated surgically (see table)
The choices of surgical approach (open or endoscopic)
and energy source (electrocautery vs laser) are techni-
cal decisions based on the patients prostate size, the
individual surgeons judgment and the patients comor-
bidities.1
Other technologies NOT RECOMMENDED
Prostatic stents are associated with significant com-
plications such as encrustation, infection and chronic
pain.
Balloon dilatation is not recommended for patients with
symptoms of BPH.
Phytotherapeutic agents and other dietary supplements
cannot be recommended for treatment of BPH

Indication for Surgery

Absolute Refractory urinary retention
Renal insufficiency due to BPH
Bladder stones
Bladder diverticulum due to obstruction
Recurrent UTI
Hematuria refractory to 5-alpha reductase inhibitor
Relative Request for active management either initially or because there is
no improvement with medical management
Surgical Therapies
Transurethral resection of the prostate
Transurethral electrovaporization
Transurethral incision of the prostate
Transurethral holmium laser resection/enucleation
Transurethral laser vaporization
Transurethral laser coagulation (visual laser ablation)
Open prostatectomy
Ideal Candidate for
Watchful Waiting
mild symptoms (AUA symptom score <7)
minimal to no bother (symptom score <7)
minimal to no interference with quality of life (quality of life score <3)
no recurrent urinary tract infection
no recurrent gross hematuria
no bladder stone
no urinary retention
no renal insufficiency related to BPH
peak flow rate >15 cc/sec
relatively low post void residual urine
Indications for Simple Open
Prostatectomy
prostate glands larger than 50 to 75 g, for which TURP is
considered inappropriate and risky
large, symptomatic bladder diverticulum
large, hard bladder stone that cannot be managed transurethrally
Alpha Blockers
Long acting selective alpha-1 terazosin 1, 2, 5 mg
doxazosin
Long acting selective alpha-1a tamsulosin 0.2 mg
alfuzosin 2.5, 10 mg

34

References
American Urological Association Practice Guidelines Committee. AUA
Guideline on Management of Benign Prostatic Hyperplasia (2003) J
Urol 2003; 170: 530-47.
Napalkov P, Maisonneuve P and Boyle P: Worldwide patterns of prevalence
and mortality from benign prostatic hyperplasia. Urology 46 (3 suppl
A): 41-46, 1995.
Oesterling JE: Benign prostatic hyperplasia: A review of its histogenesis
and natural history. Prostate Suppl 6: 67-73, 1996.
Wasson JH, Reda DJ, Bruskewitz RC, Elinson J, Keller AM, Henderson
WG. A comparison of transurethral surgery with watchful waiting for
moderate symptoms of benign prostatic hyperplasia. N Eng J Med
195; 332: 75-9.
Flannigan RC, Reda DJ, Wasson JH, Anderson RJ, Abdellatif M, Bruskewitz
RC. 5 year outcome of surgical resection and watchful waiting for men
with moderately symptomatic benign prostatic hyperplasia: A Department
of Veterans Affairs cooperative study. J Urol 1998; 160: 12-7.
Lepor, H, et. al. The Efficacy of terazosin, finasteride or both in Benign
Prostatic Hyperplasia. The New England Journal of Medicine. August
1996; 335(8); 533-539.
Nickel, JC, et al. Update on the Use of Finasteride in BPH: long-term results.
Recent Advances in Prostate CA and BPH 1996; 23-26.
Nickel JC et. al. Efficacy of alfuzosin 10 mg OD in men with LUTS, BPH and
prostatitis-like symptoms. J Urol 2005; 175(Suppl 4): 446 [Abstract 1645].
A sub-analyses of a 6 month open label study (ALF-ONE study) sug-
gested that the alpha blocker alfuzosin significantly improved LUTS,
bother, sexual function and pain/discomfort on ejaculation in men with
BPH and prostatitis-like symptoms
Debruyne, FM, et. al. The International Terazosin Trial: A Multicentre
Long-Term Efficacy and Safety of Terazosin in the Treatment of BPH.
European Journal of Urology 1996 vol. 30;369-376.
McConnell JD, Roehrborn CJ, Bautista OM, et. al. Medical Therapy of Pros-
tatic Symptoms (MTOPS) Research Group. The long term effect of doxa-
zosin, finasteride, and combination therapy on the clinical progression of
benign prostatic hyperplasia. N Eng J Med 2003; 349:2387-2398.
Gormley, GS, et al The Effect of Finasteride in Men with BPH. The New
England Journal of Medicine 1992; 327:1185-1191
Brawer, MK. et. al. Terazosin in the Treatment of BPH. Archives of Family
Medicine 193; 2:929-935.
Lepor H. Long term evaluation of tamsulosin in benign prostatic hyperplasia:
Placebo controlled, double-blind extension of phase III trial. Tamsulosin
Investigator Group. Urology 1998:51:901-6.
Lepor H. Phase III multicenter placebo-controlled study of tamsulosin in
benign prostatic hyperplasia. Tamsulosin Investigator Group. Urology
1998;51:892-900.
Benign Prostatic Hyperplasia
Madrona, EP, Ong, G, et. al. Alpha Blockade Therapy in Alternating day Dose in
the Management of BPH. VMMC Journal of Surgery November 1999; 3:3-7.
De la Rosettes JJ, Madersbacher S, Alivizatos G, et. al. European Associa-
tion of Urology: Guidelines on benign prostatic hyperplasia: 2004.
De La Rosette J. Optimising Assessment and treatment decisions for men
with BPH. Eur Urol Suppl 2006; 271:1-6
Berry SJ, et. al. Journal of Urology 1984; 132:474-9 (Prevalence of BPH).
Roehrborn CG, McConnell J, Bonilla J, et. al. Serum prostate specific antigen
is a strong predictor of future prostate growth in men with benign prostatic
hyperplasia (PLESS). J Urology 163:13-20. 2000.
Roberts RO, et. al. J Urol 2000; 163: 107-13 (Peak flow rate and volume).
Arrighi HM, et. al. J Urol 1991; 3:4-8 (Risk of surgery).
Jacobsen SJ, Jacobsen DJ, Girman CJ, Roberts RO, Guess HA, Rhodes
T, et. al. Natural history of prostatism: Risk factors for urinary retention.
J Urol 1997; 158:481-7.
Djavan B, Marberger M. A meta-analysis on the efficacy and tolerability of al-
pha1 adrenoreceptors antagonists in patients with lower urinary tract symp-
toms suggestive of benign prostatic obstruction. Eur Urol 1999; 36:1-13.
Schulman CC, et. al. Eur Urol 1996; 29:145-54.
Medical Therapy of Prostatic Symptoms Steering Committee. J Urol 2002;
167:265.
Bartsch G. et. al. Eur Urol 2000; 37:367-80 (alpha reductase enzyme).
Nkel JC. Comparison of clinical trials with finasteride and dutasteride. Rev
Urol 2004; 6: suppl 31-9.
Roehrborn CG,Boyle P, Nickel J, et. al. Efficacy and safety of a dual inhibi-
tor or 5 alpha reductase types 1 and 2 [dutasteride] in men with benign
prostatic hyperplasia. Urology 2002; 60:434-41.
McConnell JD, Bruskewitz R, Walsh P, et. al. The effect of finasteride on
the risk of acute urinary retention and the need for surgical treatment
among men with benign prostatic hyperplasia. N Engl J Med 338:
557-563, 1998.
Roehrborn CG, Marks LS, Fenter T, et. al. Efficacy and Safety of dutasteride
in the four year treatment of men with benign prostatic hyperplasia. Adult
Urol 2004 63(4): 709-715.
Will TJ, Ishani A., Stark G, et. al. Saw palmetto extracts for the treatment
of benign prostatic hyperplasia: A systematic review. JAMA 1998; 280:
1604-1609.
Bent S, Kane CI, Shinohara K, et. al. A randomized trial of saw palmetto for
the treatment of benign prostatic hyperplasia, J Urol 2005: 173(suppl
4):443 [Abstract 1537] This randomized, placebo controlled trial did not
confirm efficacy for saw palmetto in the treatment of BPH.
Mepartricin Investigators Brochure July 1997 Societa Prodotti Antibiotici
Medical Department (as provided by drug representative).
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and biochemisty following partial outlet obstruction. J Urol 1996 Dec.
156 (6): 2084-2088.

I-PSS and QOL Scores

How often do you experience Never <1 in 5 < the About = > the Almost
the following symptoms? Times Time the Time Time always

Over the past month or so, how often 0 1 2 3 4 5

There are 7 evaluated
have you had a sensation of not emptying
items.
your bladder completely after you finished
urinating?
The severity is evaluated
Over the past month or so, how often 0 1 2 3 4 5 by the total score
have you had to urinate again less than
two hours after you finished urinating?

Over the past month or so, how often 0 1 2 3 4 5

Score 0 - 7: mild
have you found you stopped and started
several times when you urinated?
Score 8 - 19: moderate
Over the past month or so, how often 0 1 2 3 4 5
have you found it difficult to postpone urination? Score 20 - 35: severe

Over the past month or so, how often have 0 1 2 3 4 5

you had a weak urinary stream?

Over the past month or so, how often have 0 1 2 3 4 5

you had to push or strain to begin urination?

Over the past month or so, how many times 0 1 2 3 4 >5

did you most typically get up to urinate from the
time you went to bed at night until the time you 0 1 2 3 4 5
got up in the morning? QOL Score
Very Satisfied Mostly So so Somewhat Dissatisfied Very Since the quality of life
satisfied satisfied dissatisfied dissatisfied of each patient varies, it
How satisfied would you feel if your bladder 0 1 2 3 4 5 6
is absolutely necessary
problem were to continue unchanged?
to evaluate QOL scores

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Benign Prostatic Hyperplasia
Recommended Therapeutics
The following index lists therapeutic classifications as recommended by the treatment guideline. For the prescriber's
reference, available drugs are listed under each therapeutic class. For drug information, please refer to the Philippine
Drug Directory System (PPD, PPD Pocket Version, PPD Text, PPD Tabs).

5-Alpha Reductase Inhibitors

Dutasteride
Avodart

Finasteride
Atepros
Finarid
Proscar
Prostanus

Alpha-Adrenergic Blockers

Alfuzosin
Fozal
Profuzin
Xatral
Xatral OD

Doxazosin
Alfadil XL

Tamsulosin
Harnal
Pimax
Prozelax

Terazosin
Conmy
Hykor
Hytrin

Estrol Fraction Binders

Mepartricin
Ipertrofan

36