Because enlargement of the prostate is nearly inevitable with age, treatment of this condition is a crucial area of investigation for urologists. The current pharmacologic treatment consists of α-blockers, 5α-reductase inhibitors (5ARIs) and combination therapy of these agents. To evaluate the current literature regarding the most effective treatment for enlarged prostate, Michael Naslund and Martin Miner review the literature and report their results in a recent issue of Clinical Therapy.
The authors first report on the natural history of the enlarged prostate, noting that the associated symptoms include increased prostate volume, decreased peak urinary flow and voided volume, worsened urinary symptoms, and increased risk of acute urinary retention and need for related surgical intervention. They emphasize that symptom scores alone are adequate to determine treatment, and that each man's perception of his symptoms must take priority. The authors identified the relevant English-language articles by searching the MEDLINE database through the first half of May 2006. They first summarize the findings for α-blockers, noting that they are more effective in treating the symptoms resulting from enlarged prostate, but are less effective in preventing disease progression. Naslund and Miner then present detailed analyses of several studies that examined the use of the 5ARIs dutasteride and finasteride. These include the prospective Proscar Safety Plus Efficacy Canadian Two Year Study (PROSPECT), the double-blind Proscar Long-Term Efficacy and Safety Study (PLESS) and an extension of the PLESS study, in which men who were originally in the placebo arm received open-label finasteride for an additional 2 years. Both PLESS and PROSPECT demonstrated reduced prostate volume, improved urinary flow rate and improved symptom scores. In their summary of three multicenter, double-blind, placebo-controlled trials, the authors note that 4325 men were randomized to receive either dutasteride or placebo over 2 years. For prostate volume, symptom scores and urinary flow rate, dutasteride was statistically significantly superior to placebo. The study was extended to examine the results of treating 2340 men who had been in either arm of the study to receive open-label dutasteride for an additional 2 years, and the results suggested that longer treatment has a greater effect. The authors also summarize the findings of several combined therapy trials: the Medical Therapy of Prostatic Symptoms (MTOPS) study, the Symptom Management after Reducing Therapy (SMART-1) trial and the Combination of Avodart and Tamsulosin (COMBAT) trial. They conclude that α-blockers are appropriate for men who have lower urinary tract symptoms and are bothered by them, whereas 5ARIs are more appropriate for men who have urinary symptoms and enlarged prostate because these drugs slow disease progression and provide long-term symptom relief.
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