Benign Prostatic Obstruction

Tables of included studies

SBU’s conclusions

Benign prostate hyperplasia (BPH) is a condition associated with ageing that affects nearly all men. Some of these men have urinary problems, and annually in Sweden around 4 500 receive surgery for an enlarged prostate. Many with mild or moderate bother are treated with medication, or require no treatment at all. If left untreated, obstructed urinary outflow can cause serious retention of urine, which damages the kidneys. Urinary retention can be life threatening.

Approximately 10 diagnostic methods are available to identify the group of men in whom an enlarged prostate causes urinary problems. Several different surgical treatment options are available; some are well established and others are experimental. Also, several drugs were introduced during the 1990s. Hence, SBU determined that a systematic review of the scientific literature addressing these different methods is necessary. The most important conclusions from this project are presented below.

• No single diagnostic method can establish that a patient has an enlarged prostate that obstructs urinary outflow. Other diagnoses must be ruled out, prostate size must be estimated, and voiding function must be assessed. A combination of several diagnostic methods can, if findings are consistent, yield a high probability for the presence or absence of obstructed urinary outflow. When findings are uncertain, a more invasive method, bladder pressure measurement, may be needed.
• The report presents reviews of two types of pharmacotherapy with different mechanisms of action. The average effect of these drugs is modest, although they might benefit some patients. Since these patients cannot be identified in advance, thorough and systematic follow-up of the outcome of medication is essential. Several phytotherapeutic agents (herbal medicines) are thought to have some effect, but the evidence is limited. Pharmaceuticals are used mainly in patients with moderate problems.
• Surgical procedures are used primarily in patients with severe problems. The most common method is transurethral resection of the prostate (TURP), which involves removing prostate tissue through the urethra. Among the less invasive procedures, transurethral microwave thermotherapy (TUMT) is most common. However, TUMT does not appear to be equally effective in improving symptoms and urinary flow rate. The risk of requiring new treatment is also greater. Various centres have developed new surgical methods intended to achieve the same effects as TURP, but with fewer side effects. It is important to disseminate such methods within the framework of scientific studies.
• Studies show that men with symptomatic prostate enlargement experience a reduction in quality of life and sexual function. Hence, the condition also affects their partner. Objective information provided before pharmacotherapy or surgery increases the individual’s knowledge and autonomy.
• Practices in treating benign prostate hyperplasia vary by county council and differ as regards the use of medication, number of operations, and choice of surgical procedure. These variations, and the reasons for them, require further analysis.
• Health economic analyses show that surgical treatment is most cost effective in men with more severe problems. Pharmacotherapy appears to be a cost effective initial alternative for men with moderate symptoms.