What Matters



Benign prostatic hyperplasia is an uncommon cause of mortality but a common cause of morbidity.

More than 80% of men aged older than 80 years have histologic evidence of benign prostatic hyperplasia (BPH). As most of us know, the most common symptoms of BPH are urinary frequency, nocturia, hesitancy, and weak urine stream. But it seems like nocturia is the source of most complaints in my panel.

Dr. Jon O. Ebbert

Interestingly, many men will experience stabilization or improvement over time without therapy. We likely do not remember this, because men who present to us are not typically enamored with the idea of "watchful waiting" when they are up all night standing at the latrine. But in fact, 38% of men will have symptom improvement over 2.6 to 5 years of follow-up without intervention.

Treatment is symptom driven. Treatment modality selections are cost and convenience driven. Many of us will reach for an alpha-adrenergic antagonist or a 5-alpha-reductase inhibitor as first-line therapy for patients with mild but annoying symptoms.

But how many of us consider NSAIDs in this setting?

Dr. Arman Kahokehr and colleagues conducted a systematic review of the literature examining the effects of NSAIDs in the treatment of men with BPH. Trials were included if they were randomized and included objective outcomes such as urologic symptom scales or urodynamics (BJU Int. 2013;111:304-11).

Three randomized trials enrolling 183 men and lasting 4-24 weeks were included in the meta-analysis. The trials used rofecoxib plus finasteride, celecoxib, and tenoxicam plus doxazosin. NSAIDs improved scores on the International Prostate Symptom Score (IPSS; P less than .001) and increased urine flow (0.89 mL/s; P = .01). No increased side effects were observed.

The authors highlight that inflammatory infiltration is seen in 43%-98% of BPH tissue, and men with acute or chronic inflammation have larger prostate volumes.

COX-2 inhibitors were used in the included studies, but nonselective NSAIDs may have as powerful an effect on the inflammatory process associated with BPH – and may be associated with less concern for adverse cardiovascular outcomes. The long-term effects of NSAIDs on kidney function and the gastrointestinal mucosa, especially in older patients, need to be considered.

But the use of NSAIDs in combination with other BPH pharmacologic agents before changing doses, medications, or intervention approach may be an attractive short-term clinical option.

Dr. Ebbert is professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He reports having no conflicts of interest. The opinions expressed are those of the author.

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