Lower urinary tract symptoms related to benign prostatic hyperplasia (BPH) and bladder outlet obstruction may affect up to 30% of men in their early 70s. Symptoms can improve without treatment, but the usual course is a slow progression of symptoms, with acute urinary retention occurring in 1% to 2% of men with BPH per year.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of medical, herbal, and surgical treatments? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 63 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: 5 alpha-reductase inhibitors, alpha-blockers, beta-sitosterol plant extract, Pygeum africanum, rye grass pollen extract, saw palmetto plant extracts, transurethral electrovaporisation, transurethral Holmium laser enucleation of the prostate, transurethral microwave thermotherapy, transurethral needle ablation, and transurethral resection (including transurethral resection versus transurethral incision, and transurethral resection versus visual laser ablation/laser vaporisation).
Symptomatic benign prostatic hyperplasia (BPH) may affect up to 30% of men in their early 70s, causing urinary symptoms of bladder outlet obstruction.
Symptoms can improve without treatment, but the usual course is a slow progression of symptoms, with acute urinary retention occurring in 1% to 2% of men with BPH a year.
Alpha-blockers improve symptoms compared with placebo and more rapidly than with finasteride, and may be most effective in men with more severe symptoms of BPH or with hypertension.
CAUTION: A drug safety alert has been issued on risk of intraoperative floppy iris syndrome during cataract surgery with tamsulosin and probably other alpha-blockers. People taking an alpha-blocker should inform their eye surgeon.
5 Alpha-reductase inhibitors (finasteride and dutasteride) improve symptoms (especially with longer duration of treatment) and reduce the risk of complications of BPH occurring compared with placebo, and are more effective in men with larger prostates.
CAUTION: A drug safety alert has been issued on the risk of male breast cancer with finasteride. Changes in breast tissue such as lumps, pain, or nipple discharge should be promptly reported for further assessment.
Saw palmetto plant extracts may be no more effective than placebo at improving symptoms. However, evidence was weak and further good-quality long-term RCTs are needed.
Beta-sitosterol plant extract may improve symptoms of BPH compared with placebo in the short term.
We don't know whether rye grass pollen extract or
are also beneficial, as few studies were found.
Transurethral resection of the prostate (TURP) improves symptoms of BPH more than watchful waiting, and has been shown not to increase the risk of erectile dysfunction or incontinence.
Some less invasive surgical techniques such as transurethral incision, laser ablation, transurethral Holmium laser enucleation (HoLEP), and transurethral electrovaporisation seem to be as effective as TURP at improving symptoms.TURP may be more effective at improving symptoms and preventing re-treatment compared with transurethral microwave thermotherapy, but causes more complications.
Transurethral microwave thermotherapy reduces symptoms compared with sham treatment or with alpha-blockers, but long-term effects are unknown.We don't know whether transurethral needle ablation is effective.