Benign Prostatic Hyperplasia: Diagnosis and Treatment

Clinical Practice Guideline

Panel Chair: John D. McConnell, M.D., University of Texas Southwestern Medical Center.
Guideline Release Date: February 8, 1994.

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In 1994, AHCPR released a clinical practice guideline to identify the most effective methods of diagnosing BPH. A multidisciplinary, 13-member private-sector panel based the guideline on syntheses of structured reviews of the literature on BPH. The guideline recommends that patients consult with their doctors and decide on a treatment based on likely treatment outcomes unless there are specific BPH complications (which usually require surgery).

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BPH Guideline Contents (Spring 1995)

• Introduction
• Guideline Recommendations
• Dissemination
• Implications
• Bibliography

Introduction

BPH, a noncancerous enlargement of the prostate gland, occurs as part of the aging process in most men. By age 80, one in four men in the United States will require treatment for the relief of symptoms associated with BPH (most commonly, difficulties with urination).

Current treatments include the following: watchful waiting (no active treatment, but periodic examinations to evaluate progression of disease); alpha blockers (drugs that can relax the smooth muscle of the bladder and prostate); finasteride (a drug that can reduce BPH); balloon dilation (a balloon inserted into the urethra is inflated to stretch it so urine flows more easily); and surgery. Prostate surgery includes transurethral resection of the prostate (TURP); transurethral incision of the prostate (TUIP); and open prostatectomy (removal of the benign prostate tumor through an incision).

After reviewing more than 1,200 abstracts from the literature, the BPH guideline panel analyzed 200 papers in depth and combined data from a variety of treatment studies. A survey was conducted to determine what treatments patients prefer if given extensive information on probable treatment outcomes. The guideline was peer reviewed and tested in clinical practice before its release.

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Guideline Recommendations

Diagnosis

• Doctors should obtain a detailed medical history from patients complaining of BPH symptoms to identify other possible causes of urinary difficulties or ailments that may complicate treatment.
• The doctor should conduct a physical examination, including a digital rectal examination, urinalysis, and serum creatinine measurement.
• The AUA Symptom Index is "the preferred instrument" for assessing the severity of symptoms. However, the AUA Symptom Index should not be used as the sole means of diagnosing BPH because the symptoms it measures are not specific to BPH.

Treatment

A patient-centered approach to treatment is central to the guideline. Unless patients have specific complications due to BPH, they should, in consultation with their doctors, decide on the treatment after understanding likely treatment outcomes. To decide on a treatment, a patient must consider how bothered he is by his symptoms and weigh how he feels about the likely benefits and risks of each treatment.

Open communication, shared decisionmaking, and patient-centered care are integral to the guideline's recommendations for treatment:

• Watchful waiting is appropriate for many patients and should be standard for those who are asymptomatic or have only mild symptoms. These patients should be monitored annually. Some patients improve without active medical or surgical treatment.
• Prostate surgery offers the best chance of symptom improvement. However, surgery also has the highest rate of significant complications. Of the available surgical procedures, TUIP has the lowest risk of operative complications. TUIP is not, however, appropriate for all patients.
• Balloon dilation is less effective than surgery (especially after 2-3 years), but has fewer complications. Because of its high long-term failure rate, balloon dilation is not commonly used.
• Alpha blockers generally cause a small increase in urinary flowrates and a small but perceptible reduction in symptoms, although not as much as surgery. Long-term efficacy is unknown.
• Generally, finasteride also causes a small increase in urinary flowrates and a small but perceptible reduction in symptoms. Full effects may not be experienced until 6 months or more of treatment. Finasteride must be taken long term. As with alpha blockers, there is no evidence that finasteride will reduce BPH complication rates or the need for surgery.

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Dissemination

After the release of the BPH guideline at a press conference in Washington, DC, on February 8, 1994, there was nationwide coverage on ABC, CBS, NBC, and CNN as well as on ECO/Televisa and Univision (Spanish-language cable networks serving the United States and Latin America). Local television and radio stations in such major markets as Boston, Chicago, Los Angeles, Philadelphia, and San Francisco also carried reports.

Press coverage in major daily newspapers nationwide included the Chicago Tribune, Los Angeles Times, New York Times, Wall Street Journal, Washington Post, and USA Today. Wire services and news syndicates covering the story included the Associated Press, Gannett News Service, Medical Tribune News Service, Reuters, and Scripps Howard.

The guideline received coverage in several major market African-American newspapers, including Afro-American (Washington, DC), Amsterdam News (New York), Muslim Journal (Chicago), and Philadelphia Tribune, as well as on American Urban Radio Network and Black Press Service.

In all, 37 African-American print and broadcast outlets carried stories, for an estimated audience of 4.5 million persons.

A video news release was produced by the American Association for Retired Persons and sent out by satellite following the press conference. All or part of the video was used by 35 television stations; it was seen by 2.68 million viewers on the 13 stations with audience figures available.

Trade media and professional journals that covered the BPH guideline include American Medical News, AHA News, Harvard Health Letter, Lancet, Medical Marketing and Media, Medical News Tribune for the Family Physician, Nurseweek, and Urology Times. American Medical Television produced a half-hour program for physicians on the guideline. CNBC aired the program, which carried continuing medical education credit.

The guideline was distributed to subscribers of Medical News Network, an interactive computer-based news service available to doctors and other health care providers in their offices. To disseminate its materials more widely, AHCPR has worked with private-sector firms. Kimberly-Clark reprinted the guideline for attendees of the AUA and American Urological Association Allied (AUAA) annual meetings. Aetna Health Claims has agreed to reprint the Consumer Version of the guideline and distribute it to up to 300,000 men covered by Medicare in the State of Washington. Aetna will compare the volume of TURP procedures before distribution of the guideline and 18 months afterwards.

To date, AHCPR has mailed out 623,000 copies of the guideline in its various versions for both providers and consumers. Bulk mailings were sent to hospitals, managed care organizations, and medical schools. Other bulk mailings were sent to national and State-level professional societies, including the American Hospital Association, AUA, Florida Nurses Association, Health Care Association of New York State, Kansas Academy of Family Physicians, Medical College of Virginia, Mid-Missouri Urologic Association, and San Francisco Veterans Hospital.

Dissemination Summary: BPH Guideline

Presentations:	5
Publications and Professional Articles:	9
Health Industry Articles:	17
Professional Mentions:	65
Consumer Print:	404
Consumer Broadcast:	95
Total:	595

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Implications

Organizations endorsing the guideline include the AUA, AUAA, American College of Radiology, American Society of Radiologic Technologists, and Society of General Internal Medicine.

The AUA took the lead in promoting use of the guideline and the AUA Symptom Index (recommended by the guideline) to its 8,000 members. In addition to mailing the guideline to members, AUA incorporated it into postgraduate activities of the AUA's Office of Education. Three different sessions at the 1994 annual AUA meeting and two AUA weekend seminars highlighted the guideline. Also, AUA's monthly newsletter, Health Policy Brief, carried information on the guideline during its development and promoted its use after publication. Internationally, a draft of the guideline served as a template for BPH recommendations issued by the World Health Organization in Paris in 1993. The panel chair and two panel members gave separate presentations on the guideline at the Society of International Urology meeting in Sydney, Australia, in September 1994.

It is too early to know whether the BPH guideline is standardizing the treatment approach or increasing the level of patient involvement in treatment decisions, but demand for the guideline publications is strong. For example, in the 4 days after the press conference, AHCPR's Publications Clearinghouse handled almost 6,700 calls for copies of the guideline.

The BPH guideline is meant to alter the treatment of BPH so that the decision to have treatment becomes patient-driven. The Consumer Version, Treating Your Enlarged Prostate, and the BPH Shared Decision-making Program, an interactive video disk based on findings from studies funded by AHCPR, provide information about risks and benefits of BPH treatments to enable men to make informed choices.

The BPH Consumer Version is being distributed by consumer education groups such as the American Foundation for Urologic Diseases Clearinghouse, Mayo Clinic Health Education Library, and the National Institute of Diabetes and Digestive and Kidney Diseases Clearinghouse. In addition, Abbott Laboratories is incorporating the AUA Symptom Index and guideline messages into consumer advertising.

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Bibliography

Benign Prostatic Hyperplasia: Diagnosis and Treatment (Clinical Practice Guideline). Publication No. AHCPR 94-0582. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, February 1994.

Benign Prostatic Hyperplasia: Diagnosis and Treatment (Quick Reference Guide for Clinicians). Publication No. AHCPR 94-0583. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, February 1994.

Benign Prostatic Hyperplasia: Diagnosis and Treatment (Consumer Version). Publication No. AHCPR 94-0584. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, February 1994.

Tratamientos para la Inflamación de la Próstata (Spanish Version of Consumer Version). Publication No. AHCPR 94-0585. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, March 1994.

Agency for Health Care Policy and Research. (1994). Benign prostatic hyperplasia: Diagnosis and treatment guideline overview. Journal of the National Medical Association 86(7), 489-549.

Benign Prostatic Hyperplasia Guideline Panel. (1994). Clinical practice guidelines, quick reference guide for clinicians. Benign prostatic hyperplasia: Diagnosis and treatment. American Family Physician 49(5), 1157-1165.

Roberts, R.G. (1994). Benign prostatic hyperplasia: Assessing severity, helping patients choose among management options. Consultant (July), 1077-1085.

Roberts, R.G. (1994). BPH: New guidelines based on symptoms and patient preference. Geriatrics 49(7), 24-31.

Roberts, R.G. (1994). Novel idea in BPH guideline: The patient as decision maker [editorial]. American Family Physician 49(5), 1044-1046, 1051.

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