Managing benign prostate hypertrophy in primary care
The prevalence of benign prostate hypertrophy (BPH) increases with age and is more common in men aged 50 years and above. Roshini Claire Anthony spoke with Dr Ronny Tan, consultant urologist and director of andrology at Tan Tock Seng Hospital, Singapore on how GPs can best manage this condition.
The prevalence of BPH rises with increased age, with early autopsy studies showing a prevalence of 8, 50, and 80 percent in the fourth, sixth, and ninth decade of life, respectively. Observational studies from Europe, US, and Asia all mirror each other in showing increased age to be the most common risk factor for onset of lower urinary tract symptoms (LUTS) due to BPH as well as progression of this disease.
Primary care physicians (GPs) are usually the first physicians that a patient consults when he feels that there is change in his urinary symptoms. The first-line of treatment would be lifestyle changes as well as oral medications which many GPs can start. These medications are usually given on a long-term basis, thus, GPs who are already taking care of the patient’s chronic diseases would be the best to deliver holistic care. Should the patient develop worsening symptoms despite being on medications or if there is a concern about prostate cancer, the GPs can then refer the patient to a urologist.
As BPH is more common in patients aged 50 years and above, GPs can be more proactive in asking patients in this age group about LUTS.
LUTS are broadly divided into voiding and storage symptoms. Voiding symptoms include hesitancy, poor stream, straining, intermittency, and sense of incomplete void. Storage symptoms include frequency (defined as more than eight voids per day), urgency, and nocturia (defined as two voids or more per night, not inclusive of the void when the patient wakes up in the morning).
GPs can also use self-administered questionnaires like the IPSS (International Prostate Symptoms Score) for objective assessment of symptoms at presentation and also during follow-up.
A digital rectal examination is mandatory in all men who present with LUTS to rule out prostate cancer.
There is no recommendation for routine screening for BPH. Having said that, health screening would include digital rectal examination. Any enlarged prostate, be it with suspicious findings or not, would be easily picked up in men above the age of 50.
Although generally due to benign prostate enlargement, LUTS in men can also be due to other problems eg, prostatitis, overactive bladder, bladder stones, vesicoureteric stones, bladder cancer, and prostate cancer.
A urine full examination microscopy elements (UFEME) is recommended and should there be microscopic haematuria or pyuria, the patient should be referred to a urologist. An elevated serum prostate specific antigen also warrants a referral to a urologist to rule out prostate cancer.
Once urinary tract infections have been ruled out, men who present with LUTS can be treated with alpha-blockers which would work within 48 hours. Patients who have both erectile dysfunction and LUTS due to an enlarged prostate can be treated with tadalafil 5 mg, as long as they are not on nitrates.
As with all diseases, should the patient not respond to the treatment administered, a referral to a urologist would be appropriate.
The main aim of BPH treatment is to delay the occurrence of urinary retention necessitating surgical intervention. Should the patient develop urinary retention, the GP can proceed to perform urethral catheterization if he/she is well equipped for that. Otherwise, the patient can be referred to the hospital for catheterization before further assessment by a urologist.
As mentioned earlier, as long as bladder cancer, prostate cancer, and stone disease is ruled out, BPH can be managed by the GP.
The medications used for treating BPH (eg, alpha-blockers, 5-alpha-reductase inhibitors, and low dose PDE5 inhibitors), are well tolerated by most patients. Common side effects of alpha-blockers include retrograde ejaculation and giddiness due to postural hypotension. The patients should have their blood pressure monitored by the GP prior to and after starting treatment with alpha-blockers.
The American Urological Association (AUA) as well as the European Association of Urology (EAU) routinely update their clinical guidelines on BPH treatment and these are available freely on their websites. However, these guidelines are mainly directed at urologists and at times, there may be too much information for the busy GP to sieve through.
In view of that, the Society for Men’s Health Singapore (SMHS) released the latest guidelines named Better Prostate Health, Simple Guidelines for Treatment of Prostate Problems in Primary Care, targeted at our colleagues in the primary healthcare sector. This set of guidelines has been formulated by urologists in the restructured and private hospitals. We also had input from a family physician making this set of guidelines more palatable and more customized for the primary healthcare physician.
Initiation of treatment for BPH can be safely started by GPs. Patients who have their BPH-LUTS well-controlled on medications can also be followed-up by GPs who are already taking care of these patients’ chronic diseases. Should there be any concerns, these patients can be jointly managed with a urologist.
Society for Men’s Health Singapore (SMHS)
American Urological Association BPH Guidelines
European Association of Urology Guidelines