Epidemiology and Treatment Modalities for the Management of Benign Prostatic Hyperplasia

Soum D. Lokeshwar; Benjamin T. Harper; Eric Webb; Andre Jordan; Thomas A. Dykes; Durwood E. Neal Jr; Martha K. Terris; Zachary Klaassen

Disclosures

Transl Androl Urol. 2019;8(5):529-539. 

In This Article

Abstract and Introduction

Abstract

Benign prostatic hyperplasia (BPH) is one of the most common conditions affecting men. BPH can lead to a number of symptoms for patients commonly referred to as lower urinary tract symptoms (LUTS). Over the last decade, increased modifiable risk factors, such as metabolic disease and obesity, have resulted in an increased incidence of BPH. This increasing incidence has brought about a multitude of treatment modalities in the last two decades. With so many treatment modalities available, physicians are tasked with selecting the optimal therapy for their patients. Current therapies can first be divided into medical or surgical intervention. Medical therapy for BPH includes 5-alpha-reductase inhibitors and alpha-blockers, or a combination of both. Surgical interventions include a conventional transurethral resection of the prostate (TURP), as well as newer modalities such as bipolar TURP, holmium laser enucleation of the prostate (HoLEP), Greenlight and thulium laser, and prostatic urethral lift (PUL). Emerging therapies in this field must also be further investigated for safety and efficacy. This narrative review attempts to consolidate current and emerging treatment options for BPH and highlights the need for additional investigation on optimizing treatment selection.

Introduction

Benign prostatic hyperplasia (BPH) is defined by the American Urological Association (AUA) as a histologic diagnosis referring to the proliferation of smooth muscle and epithelial cells within the prostatic transition zone.[1] The prostatic transition zone makes up about 5% of the prostate and is the portion that surrounds the proximal urethra. This zone is the site of continual growth throughout life.[2] The presence of BPH in older men is strongly linked to the development of lower urinary tract symptoms (LUTS), which is defined by several symptoms including urgency, nocturia, frequency, dysuria, difficulty emptying the bladder, difficulty initiating micturition, and weak or interrupted stream during micturition.[3] Although some LUTS is defined as "LUTS independent of BPH", BPH and its downstream effects lead to chronic LUTS in many men. BPH with LUTS has also been linked to erectile dysfunction (ED).[4]

The prostate was first anatomically described by Nicolo Massa of Padua in 1550.[5] It was another hundred years later, in 1649, when the enlarged prostate was proposed to cause urinary retention by Herr.[6] Since then, BPH and its role in causing symptomology has been extensively studied. As the prostatic gland enlarges, due to hyperplasia, it may lead to bladder outlet obstruction (BOO). BOO can cause LUTS by two mechanisms: (I) thickening of the prostate which physically narrows the urethra (static component), and (II) the effect of augmented smooth muscle tone (dynamic component).[7] Normally, a mixture of both mechanisms cause BOO related LUTS. Unlike the pathophysiology of LUTS in BPH patients, ED and its link with BPH is not universally understood. However, recent studies have shown that BPH may increase ED through LUTS symptoms, fibrous muscle growth, and/or through its recommended treatments.[8]

Although the diagnosis of BPH is histological, physicians utilize a multi-faceted approach in evaluating men for possible BPH. Symptom scoring, patient history, physical exam including DRE, diagnostic imaging, including ultrasound or prostate MRI, and laboratory studies are commonly used amongst physicians. Proper diagnosis also warrants an understanding of prostate size and prostatic growth rates. The average prostate is commonly described to patients as being the size of a walnut, weighing 11 grams on average, in younger adult men. The mean range falls between 7–16 grams.[9] The mean doubling time for prostatic volume is 32.6 years, with an average growth rate of around 2.2% per year.[10] The objective of this narrative review is to briefly highlight the epidemiology and pathophysiology of BPH, focus on the current treatment options for patients with symptomatic BPH, and touch on future potential directions for management. Treatments are summarized in Table 1.

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