Complications
Defined as an increase in International Prostate Symptom Score (IPSS) by 4 or more points.
Approximately 20% of patients will have progressive symptoms related to benign prostatic hypertrophy over a 5-year period. These patients typically have higher baseline prostate volumes greater than 40 g and prostate-specific antigen (PSA) levels greater than 1.4 nanograms/mL at baseline placing them at risk for progression.[53]
The Medical Therapy of Prostate Symptoms trial indicated that approximately 20% of men whose baseline characteristics demonstrated a PSA greater than 1.4 nanograms/mL and/or prostate volume greater than 40 g were subject to BPH progression as defined by an increase of the IPSS by 4 or more points.[53] A similar study has been recently published regarding the benefits of the combination of dutasteride and tamsulosin in men with moderate to severe BPH.[118]
The risk of progression is moderate in the short term.
Alpha-blockers have the most efficacies at lower prostate volumes and PSA levels. Combination therapy of 5-alpha-reductase inhibitors and alpha-blockers should be considered in patients who progress on monotherapy or have baseline higher prostate volume or PSA levels.
The reduction of overall clinical BPH progression is 66% with combination therapy and approximately 35% with either doxazosin or finasteride alone.[53]
Recurrent UTIs as a result of BPH progression were so low in the Medical Therapy of Prostate Symptoms study that it was not possible to perform a statistical analysis.[53]
Patients who develop a UTI in the setting of BPH can be treated with antibiotics in a standard fashion.
Historically there has been some concern that BPH in isolation could cause renal insufficiency in a small percentage of patients. However, the Medical Therapy of Prostate Symptoms study demonstrated no events of renal insufficiency in any of the treatment groups over a 5-year period.[53]
Another etiology for renal insufficiency should be suspected in patients who develop this in the setting of BPH.
Bladder stones may be secondary to urinary stasis.
A urinalysis and an imaging study (ultrasound or computed tomography) will be required for diagnosis. As bladder stones are usually caused by the inability to empty the bladder completely, spontaneous passage of the stones is unlikely and most cases require removal of the stones.
Hematuria may be secondary to any urinary pathology and/or hematologic disorders.
Diagnosis is made with a urinalysis and may require urine cytology and cystoscopy.
A small percentage of patients on medical therapy with either alpha-blockers or 5-alpha-reductase inhibitors may experience sexual dysfunction with therapeutic use. The incidence varies from 5% to 8% with alpha blockade and 10% to 15% with 5-alpha-reductase inhibitors or surgical management.
Prostate selective agents such as tamsulosin have been associated with ejaculatory dysfunction (e.g., retrograde ejaculation). 5-alpha-reductase inhibitors have been associated with diminished ejaculate libido and erectile dysfunction in a small percentage of patients.
Most patients continue therapy despite having some component of sexual dysfunction.[7]
Approximately 2.5% of patients with progressive BPH develop urinary retention over a 5-year period.[53]
Significant reduction in urethral lumen diameter and increased sympathetic tone contribute to acute retention.[53]
Patients with urinary retention (diagnosed via a bladder scan) related to BPH who have not been previously treated require Foley catheter placement and a trial of alpha-blocker therapy usually for 10 to 14 days. Subsequently, a trial without catheter can be considered.
Approximately two-thirds of patients will require replacement of the catheter after this trial and will most likely require additional invasive therapy.
How to insert a urethral catheter in a male patient using sterile technique.
May be associated with BPH. Treatment with alpha-blockers and antimuscarinic agents may lessen bothersome symptoms.[119] Given the complicated nature of the disease, patients with overactive bladder should be referred to a urologist.
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