THE JOURNAL OF
THE JOURNAL OF
VOL 57, NO 7 / JULY 2008 THE JOURNAL OF FAMILY PRACTICE
IN THIS ARTICLE
Benign prostatic hyperplasia:
Treat or wait?
Questionnaire with “bother score” can help you decide
• Talk to every male patient over the
age of 50 about urinary function (C).
Copyright®Dowden Health Media
• Utilize questionnaires, such as the
International Prostate Symptom Score
to evaluate the patient’s perception of
symptom severity and quality of life (A).
• Rule out potential causes of lower
urinary tract symptoms with a thorough
medical history, focused physical exam
(including digital rectal examination
and neurological assessments), and
appropriate laboratory evaluations (C).
• When choosing treatment for benign
prostatic hyperplasia, remember
that quality of life is generally more
important than symptom severity (A).
Strength of recommendation (SOR)
A Good quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented
evidence, case series
been telling me to come see you, but I’ve
been putting it off.
“I’ve been getting up 4 and 5 times
a night to urinate, and we can’t drive an
hour without me having to stop at least
once to use a restroom.”
y wife is mad at me—and she’s
worried, too,” says Dan, a 65-
year-old patient of yours. “She’s
With a deep sigh, Dan says: “My
wife is worried that I have cancer or
“And I’m worried, too,” he admits.
Benign prostatic hyperplasia (BPH), and
its clinical expression as lower urinary
urgency, nocturia, decreased force of
stream, and incomplete bladder empty-
ing—comprise a major health concern
for many older men. Approximately 50%
of men over age 60 have at least micro-
scopic BPH, while 90% over age 90 have
evidence of the abnormality.1
Many men fail to seek help for lower
urinary tract symptoms associated with
BPH,2-4 even though these often moder-
ate to severe symptoms are associated
with decreased quality of life, anxiety, and
depression.5 Your patient may be uncom-
fortable broaching the subject, as Dan
was, for fear that he may have cancer. He
may dismiss the symptoms as a natural
consequence of aging,6 or he may believe
that there are no effective treatments or
that treatment will cause unwanted side
❚ Bring up the subject
with all men over 50
To dispel these misconceptions and en-
sure that there are no current or ensuing
serious complications,4 you should rou-
tinely talk about urinary function with
John H. Davidson, MD
Division of General Internal
Medicine, Mayo Clinic,
Darryl S. Chutka, MD
Division of Preventive,
Occupational and Aerospace
Medicine, Mayo Clinic,
❚ Medical therapies
at a glance
For personal use only
For mass reproduction, content licensing and permissions contact Dowden Health Media.
that BPH is not
cancer, nor is it
to prostate cancer
VOL 57, NO 7 / JULY 2008
every male patient over age 50. Because
the incidence of BPH increases not only
with age but also with other comorbid
conditions such as diabetes7 and erectile
dysfunction (ED),8 you should discuss
the symptoms and potential complica-
tions of BPH with patients who pres-
ent with these comorbidities. You can
reassure them that BPH is not cancer,
nor is it a precursor to prostate cancer;
rather it is a fairly common, treatable
❚ Questionnaire can help,
addresses quality of life
Questionnaires such as the Interna-
tional Prostate Symptom Score (IPSS)
lar American Urological Association
symptom index (AUA-SI) (available
on page 44 of http://www.auanet.org
can help you evaluate your patient’s
The IPSS, with 3 categories of
HANDOUT)9 and the simi-
symptom severity (mild 0 to 7, mod-
erate 8 to 19, severe 20 to 35) and a
global quality-of-life question also
referred to as the “Bother Score,” is a
validated tool for monitoring disease
distress and clinical change.10,11 The
quality-of-life question is a good indi-
cator for assessing whether watchful
waiting might be preferred to active
Further categorizing the symptoms is
not helpful. Lower urinary tract symp-
toms have traditionally been divided
into irritative symptoms such as noc-
turia, urgency, and frequency, attrib-
uted to bladder and prostatic smooth
muscle contractions, and obstructive
symptoms such as hesitancy, decreased
force of stream, and incomplete emp-
tying, attributed to increased glandular
mass.1 This distinction, however, is not
helpful inasmuch as irritative symp-
toms can result from increased tissue
mass alone and obstructive symptoms
from muscle hypertonicity alone; ad-
ditionally, most BPH patients have a
combination of both.13,14
What’s right for your patient?
Watchful waiting? α α-Blocker therapy? Surgery?
• Watchful waiting should yield to
pharmacologic or surgical intervention only
when there is signifi cant symptom bother
or serious complications.
• α α-Blocker therapy alone is reasonable
with a prostate of any size, but combination
α-blocker and 5-α reductase inhibitor therapy is
more appropriate for patients with larger glands
• Surgery, especially transurethral resection
of the prostate, remains the standard for
treatment effi cacy and is associated with
unchanging or improved erectile function—
but increased ejaculatory dysfunction.
ILLUSTRATION: © 2008 KEVIN SOMERVILLE
TUMT is well-
suited to high-risk
patients or those
Benign prostatic hyperplasia
VOL 57, NO 7 / JULY 2008
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