Until recently the GP's role in the management of benign prostatic hyperplasia (BPH) was regarded primarily as one of recognition and referral.
Most patients presenting in primary care with lower urinary tract symptoms (LUTS), were managed in secondary care settings.
GPs' growing involvement in the management of BPH was recognised in 2004 when the British Association of Urological Surgeons (BAUS) adapted its guidelines on the management of LUTS for use in primary care.
Produced by a multidisciplinary working group, the new guidelines emphasise the importance of taking BPH seriously. Apart from the possibility that the symptoms of BPH are often the same as those of early prostate cancer, LUTS can seriously impair quality of life and cause major complications such as acute urinary retention.
When a patient presents complaining of LUTS, the GP's initial role is to provide reassurance and lifestyle advice and to review any medication the patient may be taking.
According to the BAUS algorithm, three key questions to ask at this stage are: are you bothered by urinary symptoms? Do you get up at night to pass urine? Have you noticed a deterioration in urinary flow?
Investigations such as digital rectal examination (DRE) and prostate-specific antigen (PSA) tests are also recommended to exclude early indicators of cancer and to help to determine the size of the prostate gland.
Many patients are not overly bothered by their symptoms and are simply seeking reassurance that they do not have prostate cancer. In these cases, once cancer has been excluded, the recommended policy is one of watchful waiting and advice on lifestyle factors such as fluid intake and avoiding caffeine (see box right).
Patients should be followed up every three to six months.
For those patients who do find their symptoms bothersome there are two categories of drug therapy available: alpha-1 blockers and 5-alpha reductase inhibitors.
If the prostate is small and the PSA less than 1.4ng/ml, the guidelines recommend a selective alpha-1 blocker as first-line treatment. Patients with large prostates and/or a PSA over 1.4ng/ml should be treated with a 5-alpha reductase inhibitor, an alpha-1 blocker or a combination of both.
Alpha-1 blockers include tamsulosin, alfuzosin and indoramin. These agents improve urine flow by blocking the stimulation of the alpha-1 adrenoceptors, thereby preventing the contraction of smooth muscle within the prostate, urethra, bladder neck and detrusor muscle.
Also, 5-alpha reductase inhibitors include finasteride and dutasteride which block the production of dihydrotestosterone thereby reducing the size of the enlarged prostate.
A combination of an alpha 1-blocker with a 5-alpha reductase inhibitor in BPH can reduce the risk of disease progression by up to 66 per cent compared to placebo, whereas the reduction was less than 40 per cent on either drug alone.
The BAUS guidelines recommend that such a combination is an option to be considered in patients with large prostates causing bothersome symptoms.
In the past, the side-effects of alpha-1 blockers have sometimes led to the discontinuation of therapy.
Subsequently, the introduction of modified-release (MR) formulations has produced a number of patient benefits such as once-daily dosing, improved patient safety and the prolonged pharmacological effect of each dose.
- Professor Kirby is a GP with an interest in cardiology in Letchworth, Hertfordshire, visiting professor at the University of Hertfordshire and director of the Hertfordshire Primary Care Research Network
LIFESTYLE TIPS FOR PATIENTS WITH BPH
- Limit your fluid intake, particularly after your evening meal and late at night.
- Reduce the amount of alcohol and caffeine in your diet.
- Avoid OTC medications that may stimulate the bladder neck and prostate or weaken bladder contractions.
- Visit the toilet at regular intervals throughout the day. Use a toilet at any available opportunity.
- Take your time urinating and concentrate on emptying your bladder as much as possible.
- Try to avoid situations that will make regular use of the toilet difficult.
- Speakman M J, Kirby R S et al. Lower urinary tract: guideline for the primary care management of male lower urinary tract symptoms. BJU Int 2004, 93: 985-90
- Djavan B, Marberger M A. Meta-analysis on the efficacy and tolerability of alpha 1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction. Eur Urol 1999; 36: 1-13
- McConnell J D, Roehrborn C G et al. The long-term effect of doxazosin, finasteride and combination therapy on the clinical progression of benign prostatic hyperplasia. N Eng J Med 2003; 349: 2,387-98
- Michel M C, Korstanje C et al. The pharmacokinetic profile of tamsulosin oral controlled absorption system (OCAS). European Urology Supplements 4 2005; 15-24
- NOP survey: benign prostatic hyperplasia (BPH). The Online Quota-Based GP Omnibus Service - August (1) 2005.