Lower urinary tract symptoms in men

Abstract

Benign prostatic hyperplasia (BPH) is a highly prevalent and costly condition that affects older men worldwide. Many affected men develop lower urinary tract symptoms, which can have a negative impact on their quality of life. In the past, transurethral resection of the prostate (TURP) was the mainstay of treatment. However, several efficacious drug treatments have been developed, which have transformed BPH from an acute surgical entity to a chronic medical condition. Specifically, multiple clinical trials have shown that α adrenoceptor antagonists can significantly ameliorate lower urinary tract symptoms. Moreover, 5α reductase inhibitors, alone or combined with an α adrenoceptor antagonist, can reverse the natural course of BPH, reducing the risk of urinary retention and the need for surgical intervention. Newer medical regimens including the use of antimuscarinic agents or phosphodiesterase type 5 inhibitors, have shown promise in men with predominantly storage symptoms and concomitant erectile dysfunction, respectively. For men who do not adequately respond to conservative measures or pharmacotherapy, minimally invasive surgical techniques (such as transurethral needle ablation, microwave thermotherapy, and prostatic urethral lift) may be of benefit, although they lack the durability of TURP. A variety of laser procedures have also been introduced, whose improved hemostatic properties abrogate many of the complications associated with traditional surgery.

Fig 1 International prostate symptom score (IPSS). Use the interactive symptom score tool at http://www.bmj.com/content/349/bmj.g4474/infographic

Fig 2 Cumulative incidence of progression of benign prostatic hyperplasia in men with moderate to severe symptoms at baseline. Progression was defined by an increase of at least four points in the American Urological Association symptom index score, acute urinary retention, incontinence, renal insufficiency, or recurrent urinary tract infections.

Fig 3 Cumulative incidence of acute urinary retention (A) and invasive treatment (B) for benign prostatic hyperplasia