Latest BPH Consensus Statements and Agreements and Disagreements from Indian Experts

Benign prostatic hyperplasia (BPH) is a global health concern with a dramatic epidemiological load of 2480/100,000 people in 2019.^1,2 In India, BPH cases exponentially increased by 90.9% between 2000 and 2019.¹ Although BPH is not life-threatening, its clinical manifestation of lower urinary tract symptoms (LUTS) significantly reduces patients’ quality of life.³ Recently, an Indian urologists’ panel reported a consensus on varied statements associated with diverse aspects of BPH, including prostate volume, prostate-specific antigen (PSA), and BPH treatment with alpha-blockers (ABs).¹

Prostate Volume and BPH Progression
Numerous studies have demonstrated prostate volume as an important predictor of BPH progression.⁴ Studies, such as the Olmsted County population-based study, confirmed that the risk of acute urinary retention (AUR) increased 3-fold with prostate size >30 mL.⁴ Further, the Baltimore Longitudinal Study of Aging reported an enlarged prostate as a positive predictor of prostatectomy.⁴ In another study, 1.6% of men with a baseline volume of <40 mL developed AUR at 2 years compared to 4.2% of men with a volume of ≥40 mL.⁴ In association with this, one of the BPH consensus statements highlighted that increased prostate volume correlates with disease progression and was supported by evidence from European Association of Urology guidelines and systematic review.¹ The consensus documented that 33.3%, 44.4%, and 22.2% of doctors strongly agreed, agreed, and disagreed with the statement, respectively.¹

Prostate-Specific Antigen in BPH
Prostate-specific antigen is a serine protease produced by the prostate gland and is found at elevated levels due to the disruption of normal prostatic architecture.⁵ Although many elements are predictive of BPH progression, serum PSA or its derivatives are the only serum markers that are constantly associated with clinical and pathologic parameters of BPH.⁶ Total serum PSA is also indicative of increasing prostate volume and of BPH progression to clinical outcomes.⁶ In association with PSA, one statement from the BPH consensus reported that PSA has a definitive role in guiding treatment decisions for patients with BPH.¹ The consensus reached only 89% among whom 44.4% agreed, 44.4% strongly agreed, and 11.1% of the experts neither agreed nor disagreed with the statement.¹ So, overall, the expert panel broadly favored the role of PSA in BPH treatment.¹

Role of Alpha-Blockers in BPH Treatment

Alpha-blockers remain the first-line therapy for BPH/LUTS.¹ All ABs have similar efficacy, but their choice is based on the patient’s comorbidities, specific side-effect profiles, and tolerance.¹ A statement mentioned that alfuzosin is a better option for LUTS/BPH treatment in sexually active males due to its lower risk of ejaculatory dysfunction compared with other ABs.¹ The consensus reached a 100% agreement, of which 22.2% agreed to the statement and 77.7% strongly agreed. This statement was supported by systematic reviews and cohort studies.¹ Another statement highlighted that silodosin has a good cardiac safety profile, making it a suitable choice for patients with LUTS/BPH and cardiac comorbidities.¹ The evidence included randomized controlled trials and observational studies, and the consensus reached 100% agreement, of which 55.5% agreed to the statement and 44.4% strongly agreed.¹ However, among alfuzosin and silodosin, alfuzosin has been indicated to have significantly higher improvements in International Prostate Symptom Score, bother score, and peak urine flow rate than silodosin.⁷

Conclusion

Around 78% of Indian urologists agree that prostate volume correlates with disease progression, 89% agree regarding the association of PSA with BPH progression, and 100% support the use of alfuzosin for sexually active BPH patients and silodosin for BPH patients with cardiac comorbidities.¹

CTA: Let's listen to the expert, Dr. N.Mallikarjuna Reddy, and delve into the varied BPH consensus statements.

1. Reddy M, Sarkar K, Sabnis R, et al. Algorithmic approach to benign prostatic hyperplasia: An Indian perspective. J Assoc Physicians India. 2024;72(7):e1–e7.
2. Ye Z, Wang J, Xiao Y, et al. Global burden of benign prostatic hyperplasia in males aged 60–90 years from 1990 to 2019: Results from the global burden of disease study 2019. BMC Urol. 2024;24(1):193.
3. Okuja M, Ameda F, Dabanja H, et al. Relationship between serum prostate-specific antigen and transrectal prostate sonographic findings in asymptomatic Ugandan males. AFJU. 2021;27:1–9.
4. Nickel JC. Benign prostatic hyperplasia: Does prostate size matter? Rev Urol. 2003;5 Suppl 4(Suppl 4):S12–S17.
5. Agrahari MK, Shrestha JK, Singh R, et al. Correlation between serum prostatic specific antigen and prostatic volume in prostatic hyperplasia. JCMS-Nepal. 2024;20(1):68–72.
6. Levitt JM, Slawin KM. Prostate-specific antigen and prostate-specific antigen derivatives as predictors of benign prostatic hyperplasia progression. Curr Urol Rep. 2007;8(4):269–274.
7. Retnayyan AP, Sreedharan SY, Rethinaswamy FP, et al. Comparison of efficacy of tamsulosin, alfuzosin, and silodosin in the management of benign prostatic hyperplasia. Asian J Pharm Clin Res. 2023;16(2):138–142.

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