Who should be treated and how? Evidence-based medicine in symptomatic BPH.

The management of benign prostatic hyperplasia (BPH), although based on the best available evidence, should be individualised to patients' circumstances and personal choices. Subjective symptoms (LUTS), bothersomeness and negative impact on the quality of life are the main reasons for the patient to seek treatment for BPH. Therefore, the improvement of this subjective discomfort ought to be an important treatment goal and criterion of appraisal. Although transurethral resection of the prostate (TURP) remains the most effective and definite way of treatment, it is less attractive from the patients' perspective, especially after medical treatments with better tolerability have become available. For this reason, the indication for surgery is nowadays set on more stringent criteria of 'appropriateness'. Several new, less-invasive surgical techniques have been introduced, but their ultimate position is difficult to appraise because of the lack of appropriate long-term data from prospective, properly designed, controlled trials, also in terms of lack of data on cost-efficiency. Therefore, medical therapy with either finasteride or alpha(1)-blockers remains an attractive therapeutic alternative: both approaches are effective, reasonably well tolerated and in the 'shorter' term more cost-efficient than TURP. Available evidence suggests that finasteride is mainly effective on a long-term basis in patients with substantially enlarged prostates. In the shorter term, alpha(1)-blockers have consistently been shown to be more effective than finasteride, irrespective of prostate size. In addition, alpha(1)-blockers have the important advantage of a rapid alleviation of subjective discomfort. To date, the combination of an alpha(1)-blocker and finasteride seems to offer no more than an alpha(1)-blocker alone. Among the alpha(1)-blockers, tamsulosin is particularly suited because of its clinical selectivity (i.e. its low risk of safety relevant cardiovascular effects) and its ease of use (once daily administration without the need for stepwise dose increments on treatment initiation). Copyrightz1999S.KargerAG,Basel