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Voiding symptoms in males are typically attributed to benign prostatic hyperplasia (BPH). A histologic diagnosis of BPH will develop in approximately half of men older than 40 years of age.
Lower urinary tract symptoms (LUTS) secondary to bladder outlet obstruction (BOO) will develop in about half of these men.1,2 Treatments for BPH are aimed at improving subjective symptoms and quality of life (QoL).
Using standardized survey instruments, such as the American Urological Association Symptom Score (AUA-SS), allows for a validated method to determine severity of disease. Those with minimal symptoms and low degree of bother can be observed or started on medications, whereas those with severe bother may require surgical intervention.
The aim of this article is to provide a contemporary review of the current management protocols for male LUTS.
Men with minimal clinical symptoms as per the AUA-SS (≤7) can be observed. In a study of men randomized to observation or lifestyle changes, those with lifestyle changes significantly reduced the frequency of treatment failure and severity of symptoms.3 These men can be advised about behavioral modifications that include fluid restriction, timed voiding, and double voiding. Observation can also be advised to those with moderate symptoms (8-19 points) with minimal bother. These patients do require periodic reevaluation to avoid recurrent infection, bladder stones, urinary retention, refractory hematuria, or renal dysfunction.
Saw palmetto is a commonly used over-the-counter medication for symptoms of an enlarged prostate, but neither the American Urological Association (AUA) nor the European Association of Urology support its use. The CAMUS (Complementary and Alternative Medicine for Urological Symptoms) trial, which included 357 men at 11 sites who were randomized to 320 mg, 640 mg, 960 mg of saw palmetto in an escalating fashion or placebo, found no difference in the escalating dose of saw palmetto compared with placebo.4
Alpha-adrenergic antagonists (alpha blockers) are considered first-line treatment for male LUTS.5,6 It has been hypothesized that BPH causes BOO and symptoms partially through increased alpha-adrenergic stimulation leading to increased urethral smooth muscle tone and intraurethral pressure. Alpha-adrenerigic antagonists, therefore, are used to treat symptoms of increased urethral resistance.
The alpha-adrenergic antagonists most commonly used for treating LUTS include alfuzosin, doxazosin, tamsulosin, and terazosin. All these agents are selective for the alpha-1 receptor subtype present in prostatic tissue. In the prostate and urethra, the alpha-1A receptor subtype is most prevalent. Numerous studies have confirmed the efficacy and tolerability of alpha-adrenergic antagonists.7-9 No single agent has been proven to be significantly more efficacious than another. Adverse effects are reported in approximately 5%-9% of patient populations taking alpha-adrenergic antagonists.10
These include dizziness, postural hypotension, asthenia, rhinitis, and sexual dysfunction, including abnormal ejaculation. The AUA Clinical Practice Guidelines Committee conducted a meta-analysis and concluded that alpha-adrenergic antagonists were beneficial in treating BOO and detrusor overactivity due to BPH.5 These agents generally improve the AUA symptom score by 4-6 points.
5-alpha-reductase inhibitors (5-ARIs)
The enzyme 5-alpha-reductase converts testosterone to dihydrotestosterone (DHT). Castration and pharmacologic agents that suppress testosterone and/or DHT production have been shown to reduce prostate size in men with BPH.11 Reducing prostate volume is hypothesized to decrease the static component of BOO caused by BPH. The 5-ARIs finasteride and dutasteride are safe and effective in the treatment of BPH. Dutasteride inhibits both type 1 and type 2 isoenzymes, whereas finasteride inhibits only the type 2 isoenzyme. Studies have found that 5-ARIs tend to be more efficacious in patients with larger rather than smaller prostates.12