STEP: Simplified Treatment of the Enlarged Prostate

M. T. Rosenberg; M. M. Miner; P. A. Riley; D. R. Staskin


Int J Clin Pract. 2010;64(4):488-496. 

In This Article

Abstract and Introduction


We propose a simple and practical approach to the identification, evaluation and treatment of lower urinary tract symptoms (LUTS) resulting from an enlarging and obstructive prostate. The proposed Simplified Treatment for Enlarged Prostate (STEP) plan is a logical guide to patient management by the primary care provider (PCP). Symptoms of enlarged prostate (EP) are common and may frequently progress into a condition with profound adverse effects on quality of life. Despite the high prevalence, EP is underdiagnosed and undertreated. This situation may result from patient- and provider-related issues. Assessment of symptoms of EP should be initiated with a discussion of LUTS. Evaluation includes a focused history, physical examination and selected laboratory tests. Certain factors put the symptomatic patient at risk for disease progression; however, not all factors can be readily evaluated in the PCP setting. The serum prostate-specific antigen (PSA) level acts both as an indicator of prostatic size and a screening tool for prostatic cancer, and thereby provides an important tool for PCPs. The STEP plan is a logical guide to patient management. Step 1, watchful waiting, is appropriate in patients with symptoms that are not bothersome. If symptoms cause bother, the initiation of an alpha-blocker (AB) in step 2, provides relatively rapid symptom improvement. Patients with bothersome symptoms and a PSA ≥ 1.5 ng/ml are at risk for progression and consideration should be given to combination treatment with an AB and a 5α-reductase inhibitor (step 3). Patients with refractory symptoms should be referred to a urologist (step 4). Identification, evaluation and management of EP are within the domain of the primary care setting. The STEP approach provides a simple and practical framework for PCPs to manage most men with symptoms of EP.


There are several undeniable facts about the prostate. First and foremost, as far as prevalence and impact is concerned, it can affect half of the population. It has a function in that it contributes volume to seminal fluid which is of obvious importance during years of fertility. It gets larger as the male ages and is located in an anatomical location that may not be completely desirable as its growth commonly obstructs emptying of the urinary bladder.[1] Many men will have an enlarged prostate (EP) and a percentage of these men will develop bothersome symptoms as a result of obstruction. Even without significant growth, a patient can experience obstructive symptoms. Either situation can cause quality of life concerns for the patient, and may even evolve into life-threatening situations when ignored.

For years the prostate has been in the domain of the urologist and the most common therapeutic intervention was surgical reduction of the gland. Beginning in the late 1980s, medications became available that provided symptomatic relief for the affected patient, which markedly reduced the rate of surgical intervention. However, symptomatic relief does not change the progression of the enlarging prostate and this growth can result in worsening symptoms in some patients. Therefore, for some patients, this treatment relieved symptoms for a short period of time and surgery was only temporarily delayed, rather than avoided.

The idea of disease progression and prevention of long-term negative outcomes is familiar to the primary care provider (PCP). Hypertension, diabetes and hyperlipidaemia are all diseases that should be treated aggressively early to prevent progression and ultimately result in better outcomes. Early identification, before symptoms have progressed, might best be accomplished in the office of the PCP. Thus, a logical follow-up question becomes, is early identification and management of the patients at risk for EP feasible in the office of the PCP?

The urological community has performed an extraordinary job in developing our understanding of the prostate, the associated symptoms, and progression potential, which in turn, makes it more practical for the PCP to be a first-line of defence, or even offence, against EP. To be adequately prepared to provide this care, the needs of the PCP can be summed up in three words, 'simple', 'effective' and 'safe': a 'simple' and efficient approach to evaluate a symptomatic patient; 'effective' treatment options that can be prescribed or performed within the primary care setting; and finally, a 'safe' approach to patient management, with minimal chance of initiating therapy that can result in a poor outcome for the patient.

In this article, we collate the recommendations of various societies for the identification, evaluation and treatment of the patient with symptomatic EP and discuss how the PCP can implement these approaches in his or her office. We understand the time constraints of the PCP in the current healthcare environment and, subsequently, offer a stepwise approach to the treatment of EP that we hope will make the process more straightforward.