Benign prostatic hyperplasia (BPH) is a common condition in older men, mainly manifested by frequent urination, urgent urination, increased nocturia and difficulty in urination.
The current treatment for patients with BPH mainly includes watchful waiting, medication, and surgical treatment.
I. Watchful waiting
Some patients feel that their symptoms have not yet affected their quality of life and are still tolerable, so they do not choose medication or surgery. And considering that these symptoms are not caused by malignant diseases such as urological tumors. Therefore, watchful waiting is often the patient’s own choice of treatment until there is an absolute indication for surgery. But watchful waiting does not mean no treatment. Watchful waiting should be a non-drug, non-surgical treatment measure that includes patient education, lifestyle guidance, and follow-up. Watchful waiting can be an appropriate management modality for most patients, especially when the patient’s quality of life has not yet been significantly affected by disease symptoms.
The components of watchful waiting should include.
(i) Patient education
Patients undergoing watchful waiting should be provided with knowledge about BPH disease and, in particular, should be made aware of the effects and prognosis of watchful waiting. Patients with BPH are often concerned about the risk of prostate cancer, and studies have shown that the detection rate of prostate cancer in people with lower urinary tract symptoms does not differ from that of their asymptomatic counterparts.
(II) Lifestyle guidance
Appropriate water restriction can relieve urinary frequency symptoms, for example, at night and when attending public social occasions. However, daily water intake should not be less than 1500 ml. Alcohol and coffee have diuretic and stimulating effects and can cause symptoms such as increased urine output, frequency and urgency, so the intake of alcoholic and caffeinated beverages should be limited. Instruction in bladder emptying techniques, such as repetitive urination. Mental relaxation training to take the attention away from the desire to urinate.
(C) Guidance on combined medications
Patients with BPH often use multiple medications in combination with other systemic diseases. These combined medications should be understood and evaluated, and if necessary, adjusted under the guidance of other specialists to reduce the impact of the combined medications on the urinary system. Treatment of coexisting constipation.
(iv) Follow-up is an important clinical process for patients undergoing watchful waiting for BPH
The first follow-up visit was conducted in the sixth month after the start of watchful waiting and annually thereafter. The purpose of the follow-up visit is primarily to understand the patient’s progress, whether clinical progression and BPH-related comorbidities and/or absolute surgical indications have occurred, and to switch to pharmacological or surgical treatment according to the patient’s wishes. Follow-up should include medical history and I-PSS, QOL score, physical examination (rectal examination), urinary routine, serum PSA, ultrasonography (including residual urine volume measurement) and urinary flow rate.
The study showed that 85% of patients on watchful waiting remained stable at follow-up to 1 year and 65% had no clinical progression at 5 years. In one study, 556 patients with BPH with moderate lower urinary tract symptoms were randomized to two groups: surgical treatment and watchful waiting, and at 3 years of follow-up, treatment failure in the watchful waiting group was found to be 8.2%, with treatment failure primarily manifested by abnormal residual urine and increased symptom scores. At 5 years of follow-up, 36% of the patients in the watchful waiting group were transferred to the surgical treatment group, and 64% remained stable.
II. Drug treatment
(i) Alpha-blockers
Alpha-blockers are used to relieve bladder outlet motility obstruction by blocking the adrenergic receptors distributed on the smooth muscle surface of the prostate and bladder neck and relaxing the smooth muscle. According to the urinary tract selectivity alpha-blockers can be divided into non-selective alpha-blockers (phenoxybenzamine, Phenoxybenzamine), selective alpha1-blockers (Doxazosin, Alfuzosin, Terazosin) and highly selective alpha1-blockers (Tamsulosin Tamsulosin).
According to the recommendations of the clinical guidelines for the management of BPH of the Chinese Society of Urology, alpha-blockers are indicated for patients with BPH who have lower urinary tract symptoms. Tamsulosin, doxazosin, alfuzosin and terazosin are recommended for the pharmacological treatment of BPH. Prazosin and the non-selective alpha-blocker phenazopyridine are not recommended for the treatment of BPH. common side effects include dizziness, headache, weakness, sleepiness, postural hypotension, and retrograde ejaculation. postural hypotension is more likely to occur in elderly and hypertensive patients.
(II) 5-alpha reductase inhibitors
5-alpha reductase inhibitors are androgen inhibitors. Both surgical and pharmacological debulking will inhibit the synthesis of testosterone or dihydrotestosterone or reduce its activity, thus acting to reduce the prostate volume in patients with BPH. The reduction in prostate volume will reduce the hydrostatic factor of bladder outlet obstruction in BPH patients, thus relieving the lower urinary tract symptoms in BPH patients and achieving the therapeutic goal of improving voiding difficulties.
At present, the 5-alpha reductase inhibitors used in China include Finasteride and Epristeride, and Dutasteride is also used abroad.
1.Finasteride
Finasteride is a selective type II 5-alpha reductase inhibitor with a mean plasma elimination half-life of 6 hours and a common dose of 5 mg daily.
A number of studies have shown that finasteride reduces the incidence of hematuria in patients with BPH and that finasteride does not affect the detection rate of prostate cancer.
The clinical guidelines for the treatment of BPH published by the Chinese Society of Urology in 2006 state that finasteride is indicated for the treatment of patients with BPH who have enlarged prostate volume with lower urinary tract symptoms. For patients at high risk for clinical progression of BPH, finasteride may be used to prevent clinical progression of BPH, such as the development of urinary retention or surgical treatment. Patients should be informed of the risk of clinical progression of BPH if they do not receive treatment, and the side effects and longer duration of treatment associated with finasteride therapy should be fully considered.
(iii) Combination of drugs
Combination therapy refers to the combined application of alpha-blockers and 5-alpha reductase inhibitors in the treatment of BPH.
The recommendation of the clinical guidelines for BPH published by the Chinese Medical Association Urology Section in 2006 is that combination therapy is suitable for BPH patients with enlarged prostate volume and lower urinary tract symptoms. patients at greater risk of clinical progression of BPH are more suitable for combination therapy. The risk of clinical progression of BPH in a specific patient, the patient’s wishes, economic status, and the increase in costs associated with combination therapy should be fully considered before using combination therapy.
(IV) Traditional Chinese medicine and botanical preparations
Traditional Chinese medicine has made indelible contributions to the development of medicine and health in China as well as to the health of the Chinese nation. At present, there are many kinds of TCM applied in the clinical treatment of BPH, but because the composition of TCM and botanical preparations is complex and the specific biological mechanism of action has not been elucidated, active basic research on various drugs including TCM is beneficial to further consolidate the international status of TCM and botanical preparations.
Currently, plant extracts have been widely adopted throughout the world, especially in European countries, to alleviate the lower urinary tract symptoms in patients with BPH. However, the current mechanism of botanicals for the treatment of BPH is not exact.
The most commonly used botanicals are currently extracts of the following plants: Saw Palmetto Berry, Pygeum africanum bark, South African Star Grass root, Urtica dioica, Pumpkin ( Cucurbita pepo) seeds, etc. There is still a lack of high-quality, large-scale, placebo-controlled, long-range clinical trials to further test the efficacy and safety of phytotherapy. Therefore large-scale randomized controlled clinical studies based on the principles of evidence-based medicine are of positive significance to further promote the clinical application of herbal and botanical agents in the treatment of BPH.