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  • Image not available. Although symptomatic benign prostatic hyperplasia (BPH) is rare in men younger than 50 years of age, it is very common in men 60 years and older because of androgen-driven growth in the size of the prostate. Symptoms commonly result from both static and dynamic factors.
  • Image not available. BPH symptoms may be exacerbated by medications, including antihistamines, phenothiazines, tricyclic antidepressants, and anticholinergic agents. In these cases, discontinuing the causative agent can relieve symptoms.
  • Image not available. Specific treatments for BPH include watchful waiting, drug therapy, and surgery.
  • Image not available. For patients with mild disease who are asymptomatic or have mildly bothersome symptoms and no complications of BPH disease, no specific treatment is indicated. These patients can be managed with watchful waiting. Watchful waiting includes behavior modification and return visits to the physician at 6- or 12-month intervals for assessment of worsening symptoms or signs of BPH.
  • Image not available. If symptoms progress to a moderate or severe level, drug therapy or surgery is indicated. Drug therapy with an α1-adrenergic antagonist is an interim measure that relieves voiding symptoms. In select patients with prostates of at least 40 g, 5α-reductase inhibitors delay symptom progression and reduce the incidence of BPH-related complications.
  • Image not available. All α1-adrenergic antagonists are equally effective in relieving BPH symptoms, but do not halt disease progression or delay surgical intervention. Older second-generation immediate-release formulations of α1-adrenergic antagonists (e.g., terazosin, doxazosin) can cause adverse cardiovascular effects, mainly first-dose syncope, orthostatic hypotension, and dizziness. For patients who cannot tolerate hypotensive effects of the second-generation agents, the third-generation, pharmacologically uroselective agents (e.g., tamsulosin, silodosin) are good alternatives. An extended-release formulation of alfuzosin, a second-generation, functionally uroselective agent, and third-generation pharmacologically uroselective agents have fewer cardiovascular adverse effects than immediate-release formulations of terazosin or doxazosin. Generic formulations are less expensive than single-source agents and should be preferentially prescribed in patients with limited financial resources.
  • Image not available. 5α-Reductase inhibitors are useful primarily for patients with large prostates greater than 40 g who wish to avoid surgery and cannot tolerate the side effects of α1-adrenergic antagonists. 5α-Reductase inhibitors have a slow onset of action, taking up to 6 months to exert maximal clinical effects, which is a disadvantage of their use. In addition, decreased libido, erectile dysfunction, and ejaculation disorders are common adverse effects, which may be troublesome problems in sexually active patients.
  • Image not available. Phosphodiesterase inhibitors are indicated in patients with moderate-severe BPH and erectile dysfunction. They improve lower urinary tract symptoms (LUTS), but do not increase urinary flow rate or reduce postvoid residual (PVR) urine volume. For these reasons, phosphodiesterase monotherapy is considered less effective than an α-adrenergic antagonist for BPH. A phosphodiesterase inhibitor may be used alone or along with an α-adrenergic antagonist.
  • Image not available. Anticholinergic agents are indicated in patients with moderate to severe LUTS with a predominance of irritative voiding symptoms. Because older patients are at high risk of systemic anticholinergic adverse effects, uroselective anticholinergic agents may be preferentially prescribed. To minimize the risk of acute urinary retention, a ...

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