GPs are well placed to treat 9 of 10 BPH patients
Family physicians or GPs, as referred to in many Asian countries, are well positioned to diagnose and treat uncomplicated benign prostatic hyperplasia (BPH), according to a leading urologist. Careful selection of patients is nonetheless crucial when starting therapy.
“Patients with prostate specific antigen [PSA] of less than 4 ng/L and no haematuria on Labstix test comprise 90 percent of BPH patients,” said Dr. Michael Wong, medical director and senior consultant at the Urology, Fertility and Gynaecology Centre, Mount Elizabeth Hospital during the 14th Urological Association of Asia (UAA) Congress in Singapore. “This means family doctors are in a position to treat 90 percent of BPH patients if they choose to do so.”
Patients aged 50 years and older who present to the clinic with bothersome symptoms and significant residual urine volume may be targeted for treatment. “Most patients would say they don’t have to receive treatment as they are not in pain and can pee, although it takes them a while to do that,” said Wong.
BPH is a progressive disease and patients should not wait long enough to start therapy. The chance of disease progression is relatively high and the goal of treatment is to protect bladder and kidney function, he added.
Treatment follows ‘open, close door concept’
Once BPH diagnosis is confirmed, understanding the concept of opening and shrinking “the door” or the bladder neck will help guide treatment decisions. “Alpha-blockers [α-blockers] open ‘the door’ and relax the smooth muscle in the bladder neck and within the prostate whereas 5alpha-reductase inhibitors [5α-ARIs] shrink the prostate tissue,” said Wong. “An advantage of alpha-blockers versus 5α-ARIs, is that they work almost immediately.”
Majority of patients with uncomplicated BPH can experience improvement in their symptoms within 4-6 weeks of treatment with α-blockers. However, as orthostatic hypotension (sudden drop in blood pressure when standing up) is the most frequent side-effect of α-blockers, patient counselling is warranted.
“Some patients will feel giddy or lightheaded when squatting down or standing up. Hence, patients are advised to take their medication with dinner in the first week of α-blocker therapy and before bedtime subsequently,” Wong said.
The risk of orthostatic hypotension is further increased when an α-blocker is combined with a phosphodiesterase inhibitor (eg, tadalafil) to treat erectile dysfunction (ED) hence, it is recommended to start on low doses and titrate cautiously when combining agents. For subclinical prostatitis, antibiotics may be considered.
In patients who fail α-blockers, “shrinking the door” using 5α-ARIs (finasteride or dutasteride) may be a reasonable option. Finasteride and dutasteride inhibit the conversion of testosterone to dihydrotestosterone, suppressing prostate growth. “These drugs are most beneficial when the prostate volume is 40 mL or greater. With 5α-ARIs, symptom relief takes about 6-8 weeks, and even longer treatment is required to achieve clinical benefit,” Wong said.
Hair growth is expected within 4-6 months of 5α-ARIs therapy and 30 percent of patients also experience reduction in ejaculatory volume. A serum testosterone test may be required if libido is low or if erectile dysfunction presents.
When to refer to urologists
Any GP who is uncertain about the progress of a patient with BPH can consider urologic referral for specialized testing. More complicated cases, such as those presenting with haematuria, palpable bladder, hard irregular prostate and confirmed urinary tract infection, may be referred to a urologist. Men with rising PSAs over 4 ng/L, particularly those with a history of prostate cancer in the family, should be referred immediately to determine screening and if biopsy is warranted.
“Shared care between urologists and family physicians ensures good patient evaluation and treatment to prevent urinary retention,” Wong said. “Singaporean men should not just aim for more cash, car, and condominium, they should also aim for continence.”