Medical therapy for BPH: expanding our treatment paradigm?

Abstract

Medical therapy for relief of symptoms of benign prostatic hyperplasia (BPH) is now a clinical reality. The challenge for urologists treating BPH with medical therapy is how to rationally employ the two proven classes of medications, the alpha blockers and ®nasteride, in their practice. To accomplish this, we must critically examine the results of multiple important clinical BPH trials published over the last decade and examine the short and long term effect of the various available medical therapies on symptoms, objective progression and consequences of the disease process and whether evidence based indicators will allow us to choose appropriate therapies. It appears that we can rationalize our medical therapy decisions, taking into consideration severity of disease, prostate size (and perhaps PSA) and most importantly, the patients' longterm expectations for treatment outcome. But ®rst physicians must decide for themselves whether to expand their treatment paradigm beyond short term symptom relief to encompass long term durability and even prevention of the consequences of the long term progression of BPH.Keywords: benign prostatic hyperplasia; prostate; ®nasteride; alpha blockers The challengeDuring the last decade medical therapy for benign prostatic hyperplasia (BPH) has become a clinical reality. 1 Two classes of medication have emerged with consistently proven results in randomized controlled trials as better than placebo: the alpha-blockers and the 5-alphareductase inhibitors. Well designed studies have proven that these medications are both safe and effective over the short term (1 y).The challenge for urologists treating BPH with medical therapy is how to rationally employ these medications in their practice. To tackle this task we must ask a number of fundamental questions: Is BPH a long term progressive disease? Should the solution for this disease with medical therapy be viewed not in terms of weeks, months or even a year, but rather be considered a life time treatment for the patient? As surgeons we have always been most interested in short term symptom relief. But now, should we be convinced that that therapy is safe over the long term, has long term ef®cacy compared to placebo, is durable over years and even decades, hopefully has the ability to halt the progression of the disease and prevent complications such as acute urinary retention or the requirement for surgery? The ultimate challenge is whether we as a urological community are ready to expand beyond short term symptom relief to long term symptom control and perhaps even prevention of disease progression with its associated complications. The problemIt appears, that in many (but certainly not all) patients with lower urinary tract symptoms, BPH can indeed be considered a slowly progressive disease. The prostate gland increases in size at an average rate of 0.6 ml/y with some age variation. 2 The average decrease in¯ow rate over time, which is an indirect measure of obstruction, is about 2 ml/sec/decade. 3,4 The frequency and severity of sy...