November 23, 2010 — Watchful waiting or active surveillance are options in selected patients with benign prostatic hyperplasia (BPH) and prostate cancer, according to a review reported in the December issue of the International Journal of Clinical Practice.
"...BPH and prostate cancer (CaP) are major sources of morbidity in older men," write J. Sausville and M. Naslund, from the University of Maryland School of Medicine in Baltimore. "Management of these disorders has evolved considerably in recent years. This article provides a focused overview of BPH and CaP management aimed at primary care physicians."
BPH may give rise to troublesome lower urinary tract symptoms and/ or acute urinary retention. Acute urinary retention may be associated with an increased risk for recurrent urinary tract infections; bladder calculi; and, occasionally, renal insufficiency. BPH may be managed with medications, minimally invasive therapies, and prostate surgery.
First-line treatment in men presenting with lower urinary tract symptoms from BPH is typically pharmacotherapy with alpha-blockers or 5-alpha-reductase inhibitors. Alpha-blockers generally work within a few days by relaxing smooth muscle, whereas 5-alpha-reductase inhibitors may take 6 to 12 months to relieve urinary symptoms. The latter drug class blocks the conversion of testosterone to dihydrotestosterone, thereby shrinking hyperplastic prostate tissue.
Malignant disease in men older than 50 years with lower urinary tract symptoms can largely be excluded by normal results on digital rectal examination, prostate-specific antigen (PSA) blood testing, and urinalysis. However, elevated PSA levels and/or a nodular prostate may be red flags for prostate cancer, and microscopic hematuria with urinary symptoms may suggest bladder cancer or prostate cancer.
Prostate cancer is a highly prevalent condition, and outcomes may be better with early detection. Although 2 large clinical trials have recently been published supporting screening for prostate cancer, mass screening is still considered controversial.
"The ageing of the population of the developed world means that primary care physicians will see an increasing number of men with BPH and CaP," the review authors write. "Close collaboration between primary care physicians and urologists offers the key to successful management of these disorders."
On the basis of a review of current literature regarding BPH and prostate cancer, the study authors note that despite increasing use of effective medical treatments, surgical intervention is still a valid option for many men. New technologies have emerged for surgical management.
Open radical retropubic prostatectomy is still the oncologic reference standard, but other well-established surgical procedures include transurethral resection of the prostate as well as use of minimally invasive techniques. A new surgical technique for prostate cancer management, now under more widespread use, is robot-assisted prostatectomy.
Other options for treatment of prostate cancer include radiation therapy, brachytherapy, high-intensity focused ultrasound, and cryotherapy. The review authors also note that not all men with prostate cancer necessarily need to be treated and that watchful waiting or active surveillance may be appropriate in some patients.
"Various protocols exist for identifying low-risk CaP and some such patients may be offered active surveillance," the review authors write. "To mitigate the danger of under-grading, these patients typically undergo repeated prostate biopsies at predetermined intervals, and PSA levels and DRE [digital rectal examination] findings are monitored. If progression of disease (increased PSA, PSAV [PSA velocity], or discovery of higher grade or bulkier cancer on biopsy) occurs, definitive therapy is offered."
The review authors have disclosed no relevant financial relationships.
Int J Clin Pract. 2010;64:1740-1745. Abstract
Additional Resource
The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) provides a comprehensive online information site on Prostatic Enlargement appropriate for patient education.
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