Changes in the Management of Benign Prostatic Hypertrophy
Edward J. McGuire, M.D., Sharon English, M.B., Ch.B., F.R.A.C.S.
The dilemma facing urologists dealing with patients complaining of a poor urinary stream and nocturia
is whom to treat and how to treat. For the last few decades, most men complaining of these symptoms
underwent a prostatectomy, as it was presumed that their symptoms were caused by an enlarged
prostate obstructing the bladder outlet. Since "prostatism" was thought to be a progressive disease, related
to the inexorable progression of prostatic size, once a man presented to his urologist with symptoms, treatment
often followed. The rate of prostatectomy in the United States increased from 30%of men with urinary
symptoms in the haven of 1960to nearly 60%in 1990and 1991according to Medicare data.lr' More recently, it
has been recognized that 25-30%of men with prostatic symptoms do not actually have outflow obstruction.
Even those patients who do have very severe symptoms and what appears to be outflow obstruction, may not
need surgery as their symptoms may wax and wane, or they may be satisfactorily relieved with conservative
management. Thus, the risk of benefit ratio for prostatectomy for males with symptoms with no clear relationship
to bladder outlet obstruction is a problem.