Philippine Urological Association, Inc.

3/F, Philippine College of Surgeons Bidg., 992 EDSA, Quezon City

TeleFax No.: 929-5501

Executive Committee and Board Members 1997

President Eduardo R. Gatchalian, M.D.
Vice President Ernesto V. Arada III, M.D.
Secretary Antonio L. Anastacio, M.D.
Treasurer Lester A. Garcia, M.D.

Board Members Jesus Benjamin L. Mendoza/M.D.

Telesforo E. Gana, Jr., M.D.
Nelson A. Patron, M.D.
benign prostatic hyperplasia

Abelardo M. Prodigalidad, M.D.

Prostate Health Committee
Chairman 1994-1996
CPM 1ST EDITION BENIGN PROSTATIC HYPERPLASIA

Algorithm for the Initial

Evaluation of Patients with Prostatism
1
Signs/
Symptoms of
Prostatism
Male 50 yrs. old
or older

Urologic
History

3
Gross or
Microscopic
Hematuria, Y
Recurrent UTI,
Retention, Bone
Pain present?
4 N
Physical
Examinations
• Abdominal
Examination
• DRE (Digital
Rectal Examination
5

Distended Y
bladder/malignant
prostated?

6 N 7

Are the
following Y Refer to
laboratory tests Urologist
positive?*

8 N 9

Initial IPSS
Evaluation (International See Figure 2
Consistent Prostate Symptom
with BPH Score)
Figure 1
* Laboratory Tests: • Urine flow rate > <10 mL/sec
• Urinalysis > (+) RBC, WBC, Protein • Residual Urine by Ultrasound > >200 mL
• PSA (Prostate Specific Antigen > elevated values • Renal Function Tests > elevated BUN and Creatinine

385
CPM 1ST EDITION BENIGN PROSTATIC HYPERPLASIA

Management After Initial Evaluation Consistent with BPH

1

Assessment
of Symptoms
(IPSS)

2 3
Mild
Symptoms
Y Watchful
Score IPSS 0-7
FR >15 mL/sec Waiting
R.U. (Wawa
= <50 mL?
4 N 5
Moderate
Symptoms
Y
Score IPSS 8-19
Bothersomeness
FR - 10-15 mL/sec
R.U.
<200 mL?
N 6 7
Mainly Alpha Adrenergic
Irritative Y Blockers
Symptoms plus • Terazosin
Small • Alfuzocin
Prostate? • Doxazosin

8 N 9
Mainly
Obstructive Volume Reducers
Symptoms plus • Finasteride
Large • Mepartricin
Prostate? • Phytotherapy

10 11

Responsive Y Continue
to Treatment
Treatment

12 N
Non Responders After
Adequate Duration or
Interim Changes in
Digital Rectal Exam
(DRE) & Prostate
Specific Antigen (PSA)
13 14
Severe Symptoms
Score Refer to
IPSS 20-35  Urologists for
FR - <10 mL/sec. Surgery
R.U. >200 mL Figure 2

387
CPM 1ST EDITION
Guidelines in the Diagnosis and Treatment of Benign
Prostatic Hyperplasia: (The Enlarged Prostate)
Introduction
Up until the late 1980s, patients with symptomatic BPH
had very limited therapeutic options so that patients
with severe symptoms were surgically treated and those
with mild to moderate symptoms were observed until
their symptoms worsen. Before the advent of medical
treatment about 80% of all men with this diagnosis
eventually underwent TURP. This last decade witnessed
a tremendous progress in the diagnosis and treatment
of BPH that included a better understanding of the
patho-physiology in BPH, discoveries of pharmaco-
logic agents, development of technological devices for
minimally invasive procedures and refinements in the
techniques and instruments used for the surgical treat-
ment of BPH.
At present, a spectrum of treatment modalities exists
for patients with symptomatic BPH extending from
watchful waiting to open surgery. In the middle of this
spectrum are the minimally invasive procedures and
medical treatment. The traditional practice of surgical
intervention by the Urologists is no longer tenable but is
gradually being replaced by the minimally invasive pro-
cedures and pharmacological agents, mostly the latter.
This spectrum allows the Urologists (and the general-
ists) to adopt a treatment modality suited to the needs
of the individual patients, taking into consideration the
efficacy and adverse effects of a particular modality, the
retreatment rate and cost of treatment. Likewise, patients
can now participate in the decision making and greatly
influence the choice of treatment options.
Lastly, the general practitioners are now heavily involved
in the treatment of BPH. They are tasked to provide an
accurate diagnosis of BPH, have adequate knowledge of
the different treatment modalities, in particular, the dif-
ferent available pharmacologic agents, their side effects
and also identify that group of patients with BPH who
may require outright referral to Urologists for workup
and possible surgery (Figure 1 - Appendix).
Definition
“The Enlarged Prostate’’: Benign Prostatic Hyper-
plasia (BPH)
BPH is the most common benign tumor in elderly male
and, is pathologically defined as the formation of benign
nodules in the transition zone and periurethral tissues of
the prostate resulting from cellular proliferation that may
lead to an increase in prostate size . Initially, these nodules
are small but enlarge and coalesce over time to produce
BENIGN PROSTATIC HYPERPLASIA
obstruction of the prostatic urethra and cause symptoms
later in life. This constellation of signs and symptoms
of obstruction and irritation are collectively referred
to as Prostatism (Clinical BPH) (Table I -Appendix).
Signs & Symptoms
The elements responsible in the production of these
symptoms are due to mechanical and dynamic fac-
tors. The mechanical factors relate to the growth and
intraurethral intrusion of the prostatic lobes which are
dependent on prostate size. The weakened urinary blad-
der wall contractility (decompensation) contributes to
the mechanical factors. Dynamic factors refer mainly
to the contraction, spasticity and rigidity of the blad-
der neck, prostatic urethra, trigone and bladder wall
resulting from stimulation mediated through the alpha-
adrenergic receptors which are abundantly distributed
in these areas.
Benign prostatic hyperplasia is responsible for urinary
symptoms in the majority of men over 50 years old.
Random autopsy findings reveal that 40% of men
in their 50's and 90% in their 80's have microscopic
evidence of the disease. Half of men over 80 years
old with grossly detectable (macroscopic) tumor will
develop symptoms.
Diagnosis
Diagnosis of BPH: “Case-Finding of BPH”
Many patients have bothersome symptoms of BPH but
do not seek professional help for fear of the discovery
of cancer, the eventuality of surgery and the false belief
that symptoms are part of the ageing process or that
frequency reflects good functioning kidneys and urinary
tract. Oftentimes patients develop urinary retention fol-
lowing surgery like cataract extraction or hernia repair,
simply because they failed to volunteer their urinary
symptoms prior to surgery or when consulting a physi-
cian for unrelated illnesses. Therefore, case finding of
BPH must be considered in males over 50 years old who
visit the clinic for any reason.
The process begins by asking three simple questions.
• Do you get up at night to urinate?
• Are you bothered by your urination habits?
• Is your urine flow decreased at all?
Any two affirmative answers to these questions warrants
further investigation and in its consensus workshop, the
Prostate Health Committee of the Philippine Urological
Association, Inc. considers the following steps manda-
389
BENIGN PROSTATIC HYPERPLASIA
tory in the initial evaluation of patient with BPH: (Figure
2 - Appendix).
Initial Evaluation
Mandatory Procedures in the Initial Evaluation of
Patients with BPH (See Figure 2 - Appendix)
• Complete medical history with emphasis on the
urinary signs and symptoms may identify other pos-
sible causes or differential diagnosis of the voiding
dysfunctions, and other co-morbidities that may or
may not be related lo BPH Prescription medicines
that affect urination must be identified
• Do general physical and abdominal and neurologic
examination thoroughly to discover abnormalities that
may or may not be related to BPH such as distended
bladder, enlarged kidneys and abnormal neurologic
findings (Figure 3 - Appendix).
• Do Digital Rectal Examination (DRE). This examina-
tion is of paramount importance in the diagnosis of
prostate disorder. Basically, it allows the physician
to determine the consistency, size, shape, mobility,
tenderness of the prostate. It also allows assessment of
the anal sphincter activity, anal lesions and others.
A normal prostate is smooth, elastic and non-tender
while a doughy and tender prostate suggests an inflam-
matory condition. BPH presents as a smooth, rubbery,
non-tender prostate while in cancer the prostate is
from firm to hard; smooth to nodular in character.
Any suspicion of prostatic malignancy requires biopsy
preferably by a Urologist. Consistency is the most
important parameter for general practitioner. The size
is difficult to assess and does not correlate with the
degree of symptoms.
• Mandatory laboratory tests includes urinalysis that
will identify hematuria, pyuria, proteinuria or other
significant findings suggestive of complicated BPH
or other kidney disorders.
• Renal Function Tests - Determination of serum Creati-
nine and Urea nitrogen is extremely important because
10% of BPH patients are azotemic.
• Serum PSA determination
Prostate Specific Antigen (PSA)
This is a glycoprotein that is secreted by the epithelial
cells of the prostate whose function is to liquify the se-
men after ejaculation. It can be detected in the serum in
increased levels in any disease of the prostate (cancer,
infection, BPH) and other conditions like urinary tract
infection, urinary retention, after urethral instrumen-
tation or ejaculation. The normal value is 0-4 ng./ml but
other methods of assay such as the 3rd generation assay
have a different normal range. It is recommended that a
390
CPM 1ST EDITION
check with the laboratory where the test is done be made
if the report does not indicate the normal range. It var-
ies with age and prostate volume (Table 2 - Appendix).
The significance of determining the PSA in the initial
evaluation of patient with BPH is identifying the risk
of that patient harboring cancer of the prostate (Table
3 - Appendix). It is not utilized to diagnose cancer of
the prostate. When used as a monitoring device, it is
important for the practitioners to remember that some
drugs or agents particularly the anti-androgens includ-
ing finasteride will influence the value or level of PSA.
Finasteride reduces the value by 50% after 3 to 6 months
of treatment. Another aspect of PSA that is important
is the so-called PSA velocity. It is the rate of increase
in the level of PSA in one year which should NOT be
more than 20% from the baseline value. Any increase
of more than 20% should arouse suspicion of cancer
of the prostate and evaluation towards this direction
is necessary.
• Urine Flow Rate
Urine flow rate determination is not mandatory but a
recommended test that is important when significant
outflow track obstruction is suspected (Table 4 - Ap-
pendix). It is easily and non-invasively performed
with the use of a uroflowmeter in the urodynamic
laboratory of a hospital or Urologists' office.
• Residual Urine Volume
Residual urine is the amount of urine left inside the
bladder after a complete voiding. Normally, no urine
should be left in the bladder but varying amounts of
residual urine can result from prostatic urethral ob-
struction or reduced detrussor contractility. It can eas-
ily be assessed with the use of ultrasound with pre and
post void scans or immediate catheterization following
completion of urination. Patients with a large amount
of residual urine (200- 300 cc.) may not respond to
medical treatment but may instead require surgery.
Pathogenesis
The exact cause of BPH is unknown. Two important fac-
tors have been observed in men with BPH and these are:
• Androgen-producing testes
• The influence of age
The role of other factors in the pathogencsis of BI'll
evolves around the androgens such that five theories are
siiggt'strd. 1 he mechanism of action of some pharma-
cologu agents iirc hasnl on some of these five concepts
(Table 5 - Appendix)
International Symptom Score
Assessment of Urinary Symptoms based
on International Prostate Symptom Score
This IPSS is designed to determine or quantify the sever-
ity of symptoms. Decisions on treatment will usually be
CPM 1ST EDITION
based on whether the symptoms are mild, moderate or
severe (Figure 4 - Appendix). Its use is highly recom-
mended not only before but also during treatment, to
monitor treatment response. It contains 7 questions or
items with 6 possible answers to which points are as-
signed depending on the severity of the symptoms, so
that the maximum score is 35 (Figure 5 - Appendix).
The quality of life assessment (QOLA) has only one
question with answers ranging from delighted to terrible
or 0-6 (Figure 6 - Appendix).
IPSS: Significance of Total Score to Treatment
(See Figure 4 - Appendix)
• Alpha-Adrenergic Blockers or antagonists have
• Mild Symptoms (0-9) - Patients in this category have
less bothersome symptoms and generally, do not re-
quire treatment. Watchful Waiting (Wawa) is usually
in order for these patients. They are re-evaluated every
6-12 mos. with IPSS and DRE.
• Moderate (10-19) - Patients in this category could
be successfully treated with pharmacologic agents.
These agents differ in the mechanisms of action, onset
of action, adverse effects and cost.
• Severe symptoms (20-35) - Most patients in this
category will need surgical intervention and, therefore
should be referred to a Urologist for proper workup
and treatment.
Treatment
The traditional surgical intervention by a urologist in the
treatment of BPH is now replaced by a trial of pharma-
cologic agents by general practitioners. There are now
several options in the treatment of BPH that one may
try before considering surgery (Figure 7 - Appendix).
Before initiating medical treatment it is important that a
diagnosis of uncomplicated BPH with moderate symp-
tom score be made. During treatment, monitoring for
response and adverse effects of the drug is important. It
is recommended that treatment be discontinued if any
of the following is observed.
• No improvement in subjective or objective para­
meters after adequate duration of treatment.
• Interim changes in DRE or TRUSP findings
• Abnormal behaviour of PSA, PSA velocity.
Drug Therapy
• Fraction Binders: Evidence shows that estrogen
The pharmacological agents used in the treatment of
BPH fall into 4 categories (Table 8 - Appendix).
• Anti-androgens: The rationale in the use of anti-
androgens for BPH is based upon the concept that
testicular androgen is necessary in the development
of BPH. Clinical trials with these agents demonstrate
BENIGN PROSTATIC HYPERPLASIA
an average reduction of prostate size by 30%. They
are more popularly used in the treatment of advanced
cancer of the prostate than BPH. 5-Alpha reductase
inhibitor (Finasteride) is the most extensively stud-
ied anti-androgen for BPH. Its main effects include
significant reduction in serum and prostatic DHT
inducing considerable prostatic involution producing
30-40% decrease in prostate volume in 3-6 months
treatment. It is given at 5 mg daily with impotence and
loss of libido as the main adverse effects occuring in
up to 5% of patients. It is also known to reduce PSA
by 50% (Table 9 - Appendix).
been in clinical use for the last 25 years. Initially,
their use was mainly as 2nd or 3rd line treatment for
hypertension but improvement in their pharmacology
led to the widespread use as 1st line treatment for
hypertension and more recently, for the symptomatic
treatment of BPH. Their use has been endorsed by
both the International Consultation on BPH and US
Agency for Health Care Policy and Research.
Two types of alpha adrenergic blockers are available
in the market:
• Long Acting: Doxazosin, Terazosin, Tamsulosin
• Short Acting: Alfuzosin, Prazosin
In general, long acting alpha-block\ers are usually
given at bedtime and require gradual dose titration
over a period of 2 to 3 weeks, improve most symp-
toms of prostatism, are effective in 60% of patients
and increase urine flow by 3-5 ml/sec. Drowsiness,
headaches are seen in 10-15% of cases, postural hypo-
tension in 2-5%. Uroselective blockers like Alfuzosin
may ha ve a rapid onset of action in "90 minutes". If
no improvement is seen within 2 to 4 months despite
adequate dose, alternative titration therapy should be
considered (Table 8 - Appendix).
Alpha Adrenergic Blockers:
• Terazosin 1-10 mg daily at bedtime; titrated over
2-3 weeks period, locally available tablets of 1 to
5 mg.
• Alfuzosin 2.5 mg 1 tab 3 x a day. No dose titration
is necessary.
• Doxazosin 4-8 mg daily at bedtime.
• Tamsulocin 0.4 mg daily at bedtime.
plays a significant role inpathogenesis of BPH and
that investigators have shown that the combined
biological effects of estrogen and androgen within the
human prostate promotes stromal hyperplasia that can
lead into clinical obstructive adenoma. Mepartricin
(Ipertrofan), a semisynthetic derivative of a polyene
antibiotic isolated from Streptomyces aureofaciens
391
BENIGN PROSTATIC HYPERPLASIA CPM 1ST EDITION

culture, binds irreversibly with androgen and estro-
genic steroids in the gastrointestinal tract leading to
increased fecal excretion of the mepartricin-steroid
complex which in turn results in somewhat serum
testosterone - estrogen ratio. It is widely used in some
countries in Europe. Usual dose is 50,000 'U'-T tablet
TID. It reduces prostate volume without affecting
libido or potency.
Controlled clinical studies showed significant im-
provement in symptom score, peak urine flow and
residual urine volume. It is currently being evaluated
in line with the guidelines recommended by the In-
ternational Consultation on BPH for Diagnosis and
Treatment of BPH.
• Phytotherapy: The use of plant extracts is the oldest
form of treatment for BPH. Some investigators claim
that they are effective for the relief of symptoms and
have minimal side effects. The locally available agent
is Pygeum africanum (Tadenan) given at 50 mg 2x a
day. It targets the prostate and the bladder inhibiting
b-FGF induced fibroblast proliferation improving
bladder contractility and reducing tissue rigidity from
fibrosis. No adverse effect on sexuality.
Minimally Invasive Procedures
Minimally Invasive Treatment Alternatives
Modem and highly technological devices are used
in this treatment alternative of BPH. Only a few of
these devices are locally available at this time, and are
mainly indicated for those patients who cannot under-
go surgery because of medical contraindications (Table
6 - Appendix).
• V-LAF= Visual laser ablation of the prostate. Its main
advantages are minimal blood loss, very short opera-
tive time, minimal complications. Long term effects
are not known at this time.
• Thermotherapy = uses urethral microwave catheter
to deliver heat to the prostate over 45oC. It has very
minimal complications and can be performed as an
out-patient procedure without anesthesia but the short
and long term results are lacking.
• Use of Urethral Stents = They are used to mechani-
cally distend the prostatic urethra thereby relieving
the obstruction.
• Electrovaporization of the Prostate = vaporization
of the prostatic tissues is accomplished by means of
a roller bar or ball (vaportrode). It has also minimal
complications and a short operative time but the main
disadvantage is the lack of a specimen for histopatho-
logical examinations.
Surgical Options
Generally, surgery to the prostate for BPH have been
refined which could be carried out through the con-
ventional "open" method or "closed" transurethral
method. Although the rate of Transurethral Resection
of the Prostate (TURP) has significantly been reduced
in the last decade because of medical agents, it is still
considered as the gold standard in the treatment of BPH.
While surgery is the most effective form of treatment,
it, however, carries a high risk of complications and
morbidity and hospitalization is necessary. This option
is indicated for a certain group of patients (Figure 7,
Table 7 - Appendix).

Medical Therapy for BPH

Onset of Mechanism of Adverse

Agent Dose
action action effects

↓
5-alpha Finasteride 5 mg/day 3-6 mths Prostate
reductase volume Impotence
inhibitors (3-5%)
Epristeride 80mg/day 3-6 mths Reverse BPH

Alpha-1 Prazosin 2 mg/day 2-4 weeks Relax Drowsiness
blockers Doxazosin 4 mg/day prostatic & headache
Alfuzosin 7.5 mg/day smooth muscle (10-15%)
Terazosin 5 mg/day Dizziness
Tamsulosin 0.4 mg/day Postural
hypotension
(2-5%)

Adopted from Shared Care for Prostatic Diseases: R and M Kirby, ] and AFitzpatrick
IS IS Medical Media, 1994

392
CPM 1ST EDITION BENIGN PROSTATIC HYPERPLASIA
Appendix Figure 3: Neurologic Examination in Urology
A. Figures
Figure 1: Candidates for Surgical Treatment
• Upper Motor Neuron Lesion (Central Lesions)
­(Urologists' Cases)
Hyperactivity: Deep Tendon Reflexes
1. Patients with urinary retention Muscular Reflexes
2. Patients with hematuria (gross/microscopic) Spasticity: Skeletal muscles
3. Patients with azotemia (elevated BUN, Creatinine)
Pathologic Toe Signs: Babinski
4. Patients with abnormal PSA and DRE findings
(suspected CA) • Lower Motor Neuron Lesion
5. Patients with dilated upper urinary tract (Peripheral Lesion)
6. Patients with acute/chronic urinary tract infection Absent Deep tendon and muscular reflexes
7. Patients not responding to medical agents. Skeletal flaccidity
Absent abnormal toe signs
Figure 2: Mandatory Procedures in the Initial
• Conal Activity
­Evaluation of Patients with BPH
Anal Sphincter (S3-S5)
• Complete medical history Anal Reflex (S5)
• General Physical Examination Bulbocavernosus Reflex (L5-S5)
• Examination of the abdomen focusing on the kidneys
and urinary bladder
• Digital Rectal Examination Figure 4: IPSS: Significance of Total Score to
• Urinalysis
• Serum BUN and Creatinine Treatment
• Serum PSA
0-9 = mild symptoms
Strongly Recommended Tests
10-19 = moderate symptoms
• Residual urine determination by ultrasound
• Urine Flow Rate 20 - 35 = severe symptoms

Figure 5: International Prostate Symptom Score

never less than less around more nearly

l in than half half the than half always
5 times the time time the time
1. In the past month, how often did
you have the feeling that your
bladder was not yet empty after
you had urinated? 0 1 2 3 4 5
2. In the past month, how often
did you need to urinate again
within two hrs of having gone
to the toilet? 0 1 2 3 4 5
3. In the past month. How often
did you notice that the flow
stopped a few times and then
started again during urination? 0 1 2 3 4 5
4. In the past month, how
often did you have difficulty in
postponing urination? 0 1 2 3 4 5
5. In the past month, how often
did you have a weak urine flow? 0 1 2 3 4 5
6. In the past month, how often
did you have to push to start a
urine flow? 0 1 2 3 4 5
5 times
never once twice 3 times 4 times or more
7. In the past month, how often
did you have to get up
at night to urinate? 0 1 2 3 4 5

393
BENIGN PROSTATIC HYPERPLASIA
Figure 6: Quality of Life based on symptoms of the urinary tract
mixed feelings generally
happy pleased generally (it makes no discon- un- terrible
contented difference) tented happy
If urination were to
stay as it is now for
the rest of your life 0 1 2 3 4 5 6
how would this
make you feel?
Figure 7: Treatment Options for BPH:
1. Watchful Waiting (Wawa)
2. Pharmacologic Agents
3. Minimally Invasive Procedure
4. Surgery
B. Tables
Table 1: Signs and Symptoms of Prostatism due
to BPH:
Obstructive Irritative
Symptoms Symptoms
1. Hesitancy and Straining 1. Frequency
2. Weak Stream 2. Nocturia
3. Prolonged and interrupted 3. Urgency
stream 4. Urgency
4. Sensation of Residual Urine incontinence
5. Urinary retention and
overflow incontinence
Table 2: PSA = Age Specific Normal Range
Age range (yes) PSA ng/ml
40-49 3.0
50-59 4.1
60-69 5.6
70-79 7.6
Table 3: PSA Range and Prostate Cancer
Range Consideration
0 -4 ng/ml normal
5-10 ng/ml elevated (abnormal)
20% chance of prostate cancer
>10 ng/ml very abnormal
60% chance of prostate cancer
394
CPM 1ST EDITION
quality of life score: S=
Table 4: Maximum Flow Rate Values
Flow Rate Interpretation
>15 ml/sec normal
10-15 ml/sec equivocal
<10 ml/sec obstruction
Table 5: Concepts in the Development of BFH
Theory Cause Effect
DHT ­­­­ ↑ 5-alpha reductase Epithelial &
hypothesis and androgen stromal
receptors hyperplasia
Oestrogen- ↑ Oestrogens Stromal
testosterone ↓Testosterone hyperplasia
imbalance
Stromal- ↑ Epidermal growth Epithelial &
epithelial factor/fibroblast stromal
interactions growth factor hyperplasia
↓ Transforming
growth factors B
Reduced cell ↑ Oestrogens Longevity
death of stroma &
epithelium
Stem cell ↑ Stem cells Proliferation
theory of transit
cells
Adopted from Shared Care for Prostatic Diseases: R and M
Kirby, J and A Fitzpatrick ISIS Medical Media, 1994
Table 6: Minimally Invasive Treatments for BPH
I. Coagulation II. Electrosurgical
Necrosis Vaporization
• Radiofrequency (TUNA) III. Prostatic Devices
• Interstitial Laser Therapy • Endourethral
• High Intensity Focus prosthesis
Ultrasound (HIFU) (Urolume)
• Microwave thermo- • Intraprostatic
therapy (>45°C) Stents (Titan)
• Hyperthemia (<45°C) • Prostacath Stents
• Visual Laser Ablation • Urospiral Stents
• Others
CPM 1ST EDITION BENIGN PROSTATIC HYPERPLASIA
Urology 29 (Suppl. 1) 2-6,1996.
Table 7: Surgical Options in BPH M. Caine: Alpha-Adrenergic Blockers for the Treatment of
Benign Prostatic Hyperplasia: The Uro. Clinics of N.A.
• Suprapubic Prostatectomy 17, No. 3,641-47; August 1990.
• Retropubic Prostatectomy L.J. Denis, R. Chris, P. Francisco, et al: Double-Blind,
• Perineal Prostatectomy Randomized, Placebo-Controlled, Multicenter Trial
• Transurethral Resection of the Prostate (TURP) Mepartricin in the Treatment of Men with BPH. Six
• Transurethral Incisions of the Prostate (TUIP) Months Follow-up. Presented at the XII Congress of the
European Association of Urology, September 1-4, 1996
- Paris, France.
Table 8: Medical Treatment of BPH H. Lepor: The Efficacy of Terazosin, Finasteride or Both in
BPH: New England J. of Medicine 335, No. 8, 533-39,
Pharmacologic Agents August 22,1996.
I. Anti-Androgens: III. Estrol Fraction
1. LHRH Agonists Binders:
2. Progestins 1. Mepartricin
3. Cyproterone Acetate 2. Testolactone
4. Flutamide 3. Atomestone
5. Finasteride
II. Alpha-Adrenergic IV. Phytotherapy:
blockers: Extracts from
1. Terazosin l. Pygeum africanum
2. Alfuzosin 2. Serenoa repens
3. Doxazosin 3. Populus fremula
4. Tamsulocin 4. Others

Table 9: Locally Available Anti-Androgen and

Adverse Effects

Anti-Androgen: Adverse Reactions:

LHRH Agonists Gynecomastia, Loss of Libido,
Progestins hot flashes
Cyproterone Acetate Loss of libido, impotence, heat
Flutamide intolerance
Finasteride Impotence, loss of libido
Tender nipples, loss of libido
Loss of libido, impotence

Bibliography:

L. J. Denis and K. Griffiths (Editors): Insights into BPH

compiled by Complit Systems Ltd, P.O. Box 630, Cardiff,
U.K.
R. and M. Kirby, J. and A. Fitzpatrick: Shared Care for Prostatic
Diseases, 1994 ISIS Medical Media Ltd. Saxon Beck, 58
St. Aldates, Oxford Oxi 1st; U.K,
James L. Pool: Unique Aspects of Doxazosin: A Third
Generation Alpha- Blocker. European Urology: 29 Sl,
March 1996.
Roger S. Kirby: Doxazosin: Safety Relative to Other Medical
Therapies for Benign Prostatic Hyperplasia. European
Urology 29:S1, March 1996.
John D. McConnel, M.D.: Androgen Ablation Blockade in
theTreatment of Benign Prostatic Hyperplasia: Urologic
Clinics of North America: 17,3, August 1990.
H. Lepor, S. Auerback, A. Puras-aez, et al: A Randomized
Placebo Controlled Multicenter Study of the Efficacy and
Safety of Terazosin in the Treatment of BPH: J. Urology
148,1467-1474, November 1992.
T. Lotti, J. Mironi, D. Prezioso et al: Observations on Some
Hormone Fractions in Patients with BPH Treated with
Mepartricin: Current Therapeutic Research 44, No. 3,
September 1988.
J.E. Altwein: Individualization of Treatment in BPH. European
395
CPM 1ST EDITION BENIGN PROSTATIC HYPERPLASIA

Drugs Mentioned in the Treatment Guideline

The following index lists therapeutic classifications as recommended by the treatment guideline. For the prescriber's
reference, available drugs are listed under each therapeutic class.

Anti-androgens
Cyproterone
Androcur.............................300
Flutamide
Fugerel.................................107
Finasteride
Proscar.................................282
Gestonorone
Primostat.............................304

Alpha-Adrenergic Blockers
Alfuzosin
Xatral...................................282
Doxazosm
Carduran..............................129
Terazosin
Hytrin..................................283

Estrol Fraction Binders

Mepartricin
Ipertrofan.............................283

Phytotherapy
Pygeum africanum
Tadenan...............................283

396