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Benign Prostatic Hyperplasia
Table 1: Risk Factors for Disease Progression
LUTS/BOO. The majority of α-antagonists currently in usage for this
indication are selective to α
1
-adrenoceptors.
Age >60 years
International Prostate Symptom Score (IPSS) >7 points
Contraction of the prostatic and bladder-outlet smooth muscle is
Prostate volume >30ml on examination
mediated by α
Prostate-specific antigen (PSA) level >1.4ng/ml (proxy for prostate volume)
1
-adrenoceptors. Inhibition of these receptors causes a
Peak flow rate >12ml/s
relaxation of this tissue, thus decreasing the ‘dynamic’ component of
Post-void residual (PVR) >100ml
bladder outflow resistance and, consequently, improving symptoms. The
improvements are rapid, with a noticeable benefit usually within 48 hours.
Table 2: Commonly Reported Side Effects Due to
Approximately 70% of sufferers will respond with this treatment and non-
α-antagonists
responders can be rapidly identified and other treatments initiated.
Cardiovascular system Postural hypotension
Headaches
Numerous large-scale RCTs have proven the efficacy of α-antagonists;
Dizziness
recent systematic reviews have confirmed that all the available
Central nervous system Dizziness
α-antagonists have a similar efficacy, tending to improve symptom scores
Asthaenia
by 30–40% and improve the maximum flow rate by 15–30%. The newer,
Somnolence
longer-acting drugs are no more effective than the older preparations.
14
Genito-urinary system Abnormal ejaculation
However, for many men the convenience of taking a once-daily
preparation will ensure better overall medication compliance.
Not all patients with symptoms require medical treatment; those with
mild symptoms (IPSS <7 points) with little impact on their QoL and who Unlike the uniform efficacy between the available α-antagonist
do not have any risk factors for progression can often be managed preparations, the safety profiles for these drugs differ due to varying
conservatively with simple advice regarding fluid intake and the affinities with α-receptors in other organ systems, particularly the
avoidance of caffeinated and alcoholic drinks. Addressing other matters cardiovascular, central nervous and genito-urinary systems (see Table 2).
such as dexterity, mobility, mental state and the use of concomitant
medications such as diuretics can also optimise the impact of the Floppy iris syndrome, which may cause technical problems during
condition on the QoL of the patient.
12
Patients selected for watchful cataract surgery, has recently been reported in men on tamsulosin
waiting should be encouraged to seek medical advice if symptoms therapy, although this phenomenon is probably not limited to tamsulosin
deteriorate so that appropriate treatment can be initiated promptly. and is likely a class effect of α-antagonist usage.
15
If medical treatment is to be commenced, several options are currently Alfuzosin
available including phytotherapy, α-adrenoceptor antagonists Open-label studies have shown that patients with cardiovascular
(α-antagonists), 5α-reductase inhibitors (5-ARIs) and combination therapy. co-morbidity or those aged over 75 years are at increased risk of
developing cardiovascular side effects with the use of short-acting
Phytotherapy alfuzosin preparations.
16
The newer prolonged-release formulations have
The use of several plant extracts (phytotherapy) has been reported to fewer age-related side effects and are associated with only a slightly
improve LUTS/BOO and they have been popular in Europe for some years.
13
increased risk of cardiovascular side effects in patients with pre-existing
hypertension.
17
Thus, for older and higher-risk patients the longer-acting
Commonly used preparations include extracts of: preparation would be recommended.
• Serenoa repens (saw palmetto) berry; Doxazosin
• Curcurbita pepo (pumpkin) seed; A number of studies have assessed the effect of doxazosin on the
• Urtica dioica (stinging nettle) root; cardiovascular system in patients with pre-existing hypertension.
• Opuntia (cactus) flower; Although not statistically significant (probably due to small numbers in
• Hypoxis rooperi (South African star grass); and hypertensive sub-groups), the data consistently showed an increase in
• Pygeum africanum (African plum tree). cardiovascular side effects in the hypertensive groups.
16
Several published studies have suggested that these extracts are as Tamsulosin
effective as α-antagonists; however, in comparison with conventional Placebo-controlled studies have shown that cardiovascular side effects
drugs the studies are often poorly designed, and the extracts have not are not significantly increased in either elderly patients or patients with
undergone the same scrutiny for efficacy, purity and safety; often it is hypertension.
18
A number of RCTs have studied the effect of concurrent
uncertain what the biological active component is. A recent World Health treatment with tamsulosin and antihypertensive drugs (nifedipine,
Organization (WHO) international consultation on urological disease enalapril and atenolol). They found no alteration in the
consensus group therefore did not recommend treatment with these pharmacodynamic response and no need to adjust the dose of the
extracts until more robust evidence exists.
14
antihypertensive drugs.
19
Alpha Blockers Abnormal ejaculation is a known side effect of treatment with an
First introduced into clinical practice for the treatment of BPH in 1978, α-antagonist.
20
No α-antagonist has been definitely shown to have a
α-antagonists remain the first-line therapy for the treatment of better profile for this side effect, although a higher incidence of abnormal
10 EUROPEAN GENITO-URINARY DISEASE 2007
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