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Benign Prostatic Hyperplasia (BPH)

Diagnosis

Symptoms of BPH (eg, weak stream, urinary hesitance, incomplete emptying, etc.) are usually related to obstruction of the urinary tract. Severity of the symptoms can be measured using the American Urological Association Symptom Index (AUASI), a widely used questionnaire that quantifies the severity of lower urinary tract blockage symptoms (Sarma 2012). The International Prostate Symptom Score, or IPSS (Zhang 2008), is another questionnaire often used for quantifying symptoms of BPH in research studies.

The first step in evaluating patients with BPH-related symptoms includes a complete overview of the patient’s general medical, neurological, and urological history, as well as their fluid and caffeine consumption, to rule out other causes of urinary tract symptoms. Medications should also be reviewed, since diuretics and antihistamine drugs may cause urinary symptoms (Sarma 2012).

Next, a digital rectal exam (DRE) is performed and PSA levels are measured (Sarma 2012). PSA levels are important because while BPH is associated with some elevation of PSA levels, a very high or quickly-rising PSA level can be a sign of prostate cancer. For example, in one study, the median PSA value in patients with BPH was 1.8 ng/mL, whereas the median PSA value among patients with prostate cancer was 13.2 ng/mL (Lakhey 2010). Still, PSA levels are not a perfect measure since levels can be normal in men with prostate cancer. Therefore, the DRE (digital rectal exam) is also important, both to help rule out prostate cancer (a smooth prostate accessible by rectal examination is less likely to be cancerous than one with hard nodules and irregularities) and to determine the size of the prostate. Classification of the prostate size as “normal,” “big,” and “very big” can help determine therapy. Measuring urine flow rates using uroflowmetry can also help assess bladder outflow obstruction (McNicholas 2008). Additional testing such as free PSA and PSA velocity also help to differentiate BPH from prostate cancer. For more information see the Life Extension Magazine article entitled “Life Saving Advances in Prostate Cancer Testing”.

The PSA Controversy

In May 2012 the United States Preventive Services Task Force (USPSTF), a panel of experts that makes recommendations on preventive medicine practices to healthcare providers in the United States, proclaimed that regular PSA testing should not be used as a screening tool for prostate cancer based upon their analysis (USPSTF 2012).

There were several problems with the USPSTF analysis. The report de-emphasized a major, high quality trial that showed robust mortality benefits by including trials of poor/ lesser quality that did not show mortality benefits, and therefore, diluted the over-all statistical effect of the higher quality trial on mortality (benefit) in their analysis.

This high quality trial was the European Randomized Study of Screening for Prostate Cancer (ERSPC), which randomized 182 000 men aged 50 to 74 from 7 countries to PSA testing every 2 to 7 years (depending on center and year) or to usual care. A prespecified analysis of 162 243 men aged 55 to 69 found that screening was associated with 20% reduction in prostate cancer-specific mortality, for an estimated 1410 men undergoing PSA screening (Schroder 2009).

After publication of the main ERSPC results, a participating center (Göteborg, Sweden) reported their results separately. This site determined that a PSA screening threshold of 2.5 to 3.0 µg/L every 2 years in 20, 000 men aged 50 to 64 years decreased risk for prostate cancer-specific mortality by 44% after a median of 14 years (Hugosson 2010).

Poor-quality trials included by the USPSTF in their analysis statistically diluted the beneficial effect observed in the higher quality ERSPC trial in their over-all assessment. Several lesser/ poor quality trials found no difference between screening-invited and control groups in prostate cancer-specific mortality risk (Kjellman 2009; Sandblom 2011). Major methodological flaws in these trials included failure to adequately control for randomization and/ or poor allocation blinding, poor attempts to capture lost data points, etc. One trial even used an exorbitantly high PSA cut point – 10 µg/L – as a screening threshold (Kjellman 2009).

Life Extension advocates the use of PSA screening to prevent prostate cancer deaths, with an important caveat– PSA results should be tracked and monitored over time (ie, PSA velocity) with less emphasis being placed on individual test results. Life Extension issues a cautionary advisory whenever PSA levels exceed 1.0 ug/L. A level of say 1.4 should be closely followed with PSA blood tests every 6-12 months to carefully track any consistent increase indicative of an early stage prostate tumor that may be treatable with lifestyle changes and medications with low side effect profiles.

Life Extension has examined this issue in detail. For more information please see the Life Extension magazine multi-part series entitled “The PSA Controversy”.