REP ORT

EP

MEDICAL
assessment

MANAGEMENT
technology

OF SYPTOMATIC
BENIGN
health

HEALTH TECHNOLOGY ASSESSMENT UNIT

MEDICAL DEVELOPMENT DIVISION
MINISTRY OF HEALTH MALAYSIA
MOH/P/PAK/46.02 (TR)
This Health Technology Assessment Report has been prepared from information based on
literature reviews and expert opinion. It has been externally reviewed and approved by the
Health Technology Assessment Council, Ministry of Health Malaysia. Queries and comments
should be directed to:

Head, Health Technology Assessment Unit,

Medical Development Division,
Ministry of Health Malaysia
21st Floor, PERKIM Building.
Jalan Ipoh, 51200 Kuala Lumpur.
Malaysia.

Tel: 603-40457639
Fax: 603-40457740
e-mail: [email protected]
 MEMBERS OF EXPERT COMMITTEE
1. Dr. Mohd Yusof Abdul Wahad Chairman
Senior Consultant Surgeon
Tengku Ampuan Rahimah Hospital, Klang

2. Dr. Wan Usamah Wan Hussein

Senior Consultant Surgeon
Tengku Ampuan Afzan Hospital, Kuantan

3. Dr. Choong Wooi long

Senior Consultant Urologist
Kuala Lumpur Hospital

4. Dr. B. Venugopalan
Assistant Director
State Health Director’s Office. Selangor

Project Coordinators
1. Dr. S. Sivalal
Deputy Director
Health Technology Assessment Unit,
Medical Development Division.
Ministry of Health Malaysia
2. Dr. Rusilawati Jaudin
Principal Assistant Director
Health Technology Assessment Unit,
Medical Development Division.
Ministry of Health Malaysia
3. Ms. Sin Lian Thye
Nursing Sister
Health Technology Assessment Unit,
Medical Development Division.
Ministry of Health Malaysia
 EXECUTIVE SUMMARY
Benign Prostatic Hyperplasia (BPH) is a non-malignant enlargement of the prostate effecting
about 50% of men aged 60 years and above. This enlargement is a normal consequence of
aging and is rarely life threatening but may produce distressing symptoms.

The prevalence of BPH is said to be high, but patients’ only seek treatment when a critical
level of bother has been reached. In Malaysia, results from a campaign on health awareness of
BPH in Hospital Kuala Lumpur found a prevalence of 35/100 in self referred participants aged
50 years and above.

The terminology associated with BPH has changed from “Prostatism” to lower urinary tract
symptoms’, whereas traditional symptoms are categorized as irritative or obstructive
symptoms.

There are various methods to diagnose BPH, the quantification of symptom severity being
recognized as the best diagnostic tool and best predictor of the condition. The most widely
used scoring system is the American Urological Association symptom index for BPH, which
was later, modified as International Prostate Symptom Score (IPSS). Another method is using
uroflometry to measure the peak urinary flow and residual volume by ultrasound or by
catheterization.

The treatment options for symptomatic patients with BPH fall into four distinct catagories
- assurance and advice/watchful waiting, pharmacological intervention using alpha receptor
blockers, 5 alpha reductase inhibitors and phytotherapy, surgical treatment using
endoscopic methods like TURF, TUIP or laser prostatectomy and open prostatectomy, and
other treatment methods such as microwave/radiowave, stents and balloon dilation.

The objectives of this assessment are to determine the effectiveness, safety and cost
implications of the various modalities of medical management of symptomatic BPH.

There is sufficient evidence that alpha-blockers and 5 alpha reductase inhibitors are effective to
treat moderate symptoms of BPH. Alpha blocker are safe for normotensive and controlled
hypertensive elderly patients, with Tamsulosin having least side effects compared to other
alpha adrenoceptor blocker. 5alpha reductase inhibitors have minimal sexual related side
effect, but is otherwise safe and well tolerated. With respect to cost implications there is
sufficient evidence to support medical management of BPH in older patients, since it is only
cost effective for a short time horizon. Alpha-blocker are more cost effective than alpha
reductase inhibitors. There is insufficient evidence to support the effectiveness and safety of
phytotherapy.

Medical management is thus recommended for elderly patients with mild to moderate BPH.
 TABLE OF CONTENTS
1. INTRODUCTION 1
1.1 Background 1
1.2 Symptoms and Natural History 1
1.3 Symptom Assessment and Symptom Scores 2
1.3.1 Symptom score 2
1.3.2 Objective measures 2
1.4 Treatment 2
1.4.1 Reassurance and advice / watchful waiting 2
1.4.2 Pharmacological management 3
1.4.3 Surgical intervention 4
1.4.4 Other treatment methods 4

2. OBJECTIVES 4

3. METHODOLOGY 4

4. RESULTS & DISCUSSION 5

4.1 Effectiveness 5
4.1.1 Alpha-blockers 5
4.1.2 Five alpha reductase inhibitors 5
4.1.3 Phytotherapy 5
4.2 Safety 6
4.2.1 Alpha-blockers 6
4.2.2 Five alpha reductase inhibitors 7
4.2.3 Phytotherapy 7
4.3 Cost Implications 7
4.3.1 Surgical vs Medical Management of BPH 8
4.3.2 Medical Management of BPH 8

5. CONCLUSIONS 8

6. RECOMMENDATIONS 9

7. REFERENCES 10

8. EVIDENCE TABLE 13

APPENDIX 1 15

APPENDIX 2 16
1. INTRODUCTION
1.1 Background
Benign prostatic hyperplasia (BPH) is a non-malignant enlargement of the prostate and it
affects about 50% of men aged 60 years and over. This enlargement is a normal consequence
of aging as has been shown by autopsy studies of histological prevalence of 82% in men aged
71-80 (Berry et al. 1984). This enlargement, though rarely life-threatening, may produce
distressing symptoms.

Evidence from studies reveal that the prevalence of BPH is high, but treatment is only sought
when a critical level of bother has been reached (Pinnack et al. 1996; Ward and Sladden, 1994;
MacFarlane et al. 1995). In Malaysia, the lack of local studies on the epidemiology of BPH, as
well as the absence of a registry for BPH, make it difficult to estimate the prevalence of
symptomatic BPH. However, it may be a significant problem as indicated by the results of a
recent campaign on health awareness on BPH in Kuala Lumpur Hospital, that found a
prevalence of symptomatic BPH of 35 per 100 in self-referred participants of the campaign
aged 50 years and above.

1.2 Symptoms and Natural History

The terminology associated with BPH has also changed during the last decade. The term
“prostatism” was formerly used broadly to describe urinary symptoms in elderly men.
Currently, the terminology of “ lower urinary tract symptoms” has been proposed as a more
adequate expression. Traditionally symptoms of BPH were categorized into irritative or
obstructive symptoms. More recently, these symptoms have been classified as voiding or
storage symptoms as indicated below.

Storage Symptoms Voiding Symptoms

• Frequency • Hesitancy
• Urgency • Poor flow
• Nocturia • Intermittent flow
• Urge incontinence • Post-micturition dribble
• Incomplete emptying

The symptoms of frequency, urgency and nocturia are usually cited as the most ‘bothersome’
(du Beau et al. 1995). Clinically diagnosed but untreated BPH shows a variable pattern of
exacerbation and remission, and it is not possible to predict which of these patients will
deteriorate if left untreated. However, the reported annual incidence of the progression of
symptoms of BPH to urinary retention is in the range of 0.4% - 6% (Roehrborn, 1996). Studies
have shown that there is poor correlation between urinary symptoms and the degree of
prostatic enlargement (Barry et al. 1993; Girman et al. 1995; Simpson et al. 1996). This makes
the issue of who should be treated and when, a difficult one.

1.3 Symptom Assessment and Symptom Scores

1.3.1 Symptom score
In the diagnosis of BPH, the quantification of symptom severity is recognized as the best
diagnostic tool and is the best predictor of the condition. It enables the patient and his doctor to
determine the nature and severity and the impact they are having on his well-being. The most
widely used scoring system is the American Urological Association symptom index for BPH.
This has subsequently been modified as the International Prostate Symptom Score (IPSS) with
the addition of an extra question relating to the impact of the symptoms on the quality of life. It
is a self-administered seven-question instrument (Appendix 1). A classification of mild (0-7),
moderate (8-19) or severe (20 to 35) is used to plan and monitor treatment. This score has
been shown to have high internal consistency and test-retest reliability (Wernberg, 1995).

1.3.2 Objective measures

The peak urinary flow rate, measured by uroflometry, is a non-invasive indicator of bladder
outlet obstruction. However, the peak flow rate can be influenced by other factors including
impaired detruser function, and hence it may not correlate well with the degree of obstruction.
A peak flow rate between 10 to 15 ml/s with a minimal voided volume of 150 ml is regarded as
normal. However, for the baseline rate of any patient, the use of flow rates on two separate
occasions has been recommended (Roehrbornd et al. 1996). Improvements of greater than 3
ml/second are frequently used as measures of success of treatment in studies analyzing
efficiency of surgical or medical treatments (Reynard and Abrams, 1995).

Another measure is that of residual volume, which can be achieved by ultrasound or by

catherisation. However, there is a very wide void-to-void variation in post void residual
volume, which makes the use of this parameter for treatment decision and evaluation of
treatment, difficult to interpret.

1.4 Treatment
The treatment options for symptomatic patients with BPH fall into four distinct categories:
- Reassurance and advice/watchful waiting
- Pharmacological intervention
- Surgical treatment
- Other treatment methods

1.4.1 Reassurance and advice/watchful waiting

A proportion of patients with mild to moderate symptoms of BPH improve spontaneously over
time, with no active intervention, a therapeutic option termed watchful waiting (WW).
Therefore, in cost-effective analysis of various treatment modalities, WW has often been used
as one of the treatment arms in the analysis.

1.4.2 Pharmacological management

The medical treatment of BPH should be regarded as an option in its own right and not only as
an interim measure while waiting for surgery. The drugs used in symptomatic BPH can be
grouped into three major categories as follows:
α1 receptor blockers
The alpha-one (α1) blockers have an antagonist effect on the alpha adrenoceptors in the
prostate smooth muscle. The resultant relaxation of the smooth muscle decreases the prostate
tone on the urethra and hence, reduces the urethral resistance. The α1 receptor blockers
currently available for treatment of BPH in Malaysia include Prazosin, Terazosin, Doxazosin
and Alfuzosin. Another α1 receptor blocker, Tamsulosin, is widely used in Japan and Europe,
purportedly with a much better safety profile than the rest.

a) 5α-reductase inhibitors
5α-reductase inhibitors prevent the conversion of testosterone to its active form
dihydroxytestosterone, which is important for the growth and differentiation of the prostate. A
reduction of dihydroxytestosterone there will reduce the volume of the prostate, leading to a
decrease in the urethra flow resistance. The time of onset of action for 5α-reductase inhibitors
is reported to be between 3-6 months. The only 5α-reductase inhibitor currently on the market
is Finasteride.

b) Phytotherapy
There has been various plant extracts used to treat BPH, but the mechanism of action of
phytotherapy is not well understood. Some of the natural remedies available that have been
used to treat BPH include Carnilton (a pollen extract), Cubicin (derived from pumpkin seeds),
Serenoa repens, certinin and pygemy africanum.

1.4.3 Surgical intervention

Surgery is generally considered for those patients with severe symptoms of BPH.

1. Endoscopic methods
• TURP (Transurethral Resection of Prostate) is considered the gold standard of surgical
management. This involves resection/removal of the inner tissue of the gland via the
urethra using electro-cautery.

• TUIP (Transurethral Incision of Prostate), also referred to as bladder neck incision,

involves making one or two incisions in the prostate to relieve constriction.

• Laser prostatectomy consists of 2 main techniques: TULIP – transurethral ultrasound-

guided laser prostatectomy and ELAP/VLAP- visual laser prostatectomy.

2. Open prostatectomy
Open prostatectomy is used for particularly large glands (70-80 gm) and for patients
with complicated BPH, urinary retention and patients with hip problems, which prevent
the patient from being able to be correctly positioned for TURP.
1.4.4. Other treatment methods

a) Microwaves/Radiowaves

• Microwave involves raising the temperature above body temperatures but less than
45ºC. The may be delivered either transrectally or via the transurethral route, and
results in coagulative necrosis of the gland.

• Radiowaves – transurethral needle ablation (TUNA) involves transmission of low

frequency radiowaves through needles placed directly into the prostatic lobes. It
produces well -defined necrotic lesions, but spares the urethra.

b) Stents

Stents are flexible prostheses inserted into the urethra to hold the prostatic lobes apart.
They are used for patients who would need permanent catheter drainage because they
are unsuitable for surgery.

c) Balloon Dilatation

Balloon dilation involves stretching the prostatic urethra by the inflation of a balloon.
Tears or splits are produced through the stroma along the length of the prostate. This
procedure only produces temporary relief of symptoms. This is the least invasive of
non-medical therapies.

2. OBJECTIVES

To determine the effectiveness, safety and cost implications of the various modalities of the
medical management of symptomatic BPH.

3. METHODOLOGY

An electronic search of the MEDLINE database using the following search criteria was
carried
out:
Key words used: prostate, costing, cost- effectiveness
Years searched: 1995- 2001
Number of titles reviewed: 56
Relevant full text articles reviewed: 6
Relevant abstracts reviewed: 5

In addition the following journals and reports were searched on- line: Effective Health Care
 and Health Technology Assessment Reports. Apart from this, relevant journals were hand-
searched from the medical library of the University of Malaya.

Literature was systematically reviewed and the evidence graded according to the modified
CAHTA Scale (Appendix 2).

4. RESULTS & DISUSSION

4.1 Effectiveness

4.1.1 Alpha-blockers.
Several randomized placebo controlled trials have demonstrated that alpha one blockers are
effective in the treatment of BPH, with the onset of action 2-4 weeks after initiating treatment.
(Okada, 2000; Buzelin, 1997; Lee, 1997). The main study outcome was measured by peak
urinary flow rates (Q max) and symptom scores in most of the studies. Some studies have used
failure of medical treatment, defined as developing acute urinary retention or need for surgical
intervention (Clause, 1996). Other studies have used residual volume as a means to measure
outcome (Lee 1997). It was noted however that in many of the studies there was lack of
standardization, different inclusion criteria were used, different symptom scores were utilized
and even different minimal voided volume for the measurement of Q max were used. This
makes quantitative comparison between the study groups difficult.

It was demonstrated that α1- blockers improves the Q max by 20-30%, with an improvement of
urine flow up to 2.2 ml/s while the symptom score improved by 25-44% (Lee, 1997; Buzelin,
1997; Kirby, 1997; Claus, 1996; Mostaafa, 1996). There is a reduction in treatment failure in
the α1 blockers treated group as compared to the placebo group (Clause, 1996)

4.1.2 Five alpha reductase inhibitors

The only drug in this group currently available on the market is Finasteride.
A review, (Otten, 1996), found that the choice of Finasteride was dependent on life expectancy
and the severity of symptoms on presentation. There are two main wellconstructed RCT
regarding the use of 5α-reductase inhibitors that contradict each other. The study by Lepor et
al (1996) showed that there was no significant improvement in the symptom score and Q max
in the patients treated with 5α-reductase inhibitors as compared with those treated with a
placebo, except for a reduction in the prostate volume. In the study by McConnel et al.(1998)
in those patients treated with 5α-reductase inhibitors, there was a reduction in surgery,
reduction of acute urinary retention, decrease in the symptom score, increase in Q max, and an
overall decrease in the prostate volume. Hudson et al.(1999 ) also showed that the symptom
score improved, Q max increased, with the prostate volume decreasing at 24 months on
therapy with 5α-reductase inhibitors. A study by Eri and Tveter, (1997) showed that
Finasteride was most effective in men with large prostates (> 40 mm). For patients with
moderate symptoms and a life expectancy of 3 years or less, Finasteride produced a better
quality of life than Watchful Waiting (WW).
4.1.3 Phytotherapy
Two major systematic reviews of phytotherapy by Wilt et al. (1998, 1999) showed that existing
studies are limited by short study duration and lack of standardization in the plant extract used.
In view of this, the efficacy of phytotherapy in the treatment of BPH at the moment cannot be
established, and further studies are needed to determine the role of phytotherapy in the
treatment of BPH.

4.2 Safety
4.2.1 Alpha-blockers
The side effects profile for each of the drug can be categorised into two broad groups:-
1) Side effects due to 5α-1 receptor blockade at sites other than the prostate
2) Other side effects unrelated to the above

Safety concerns on the use of α1- receptor blockers in BPH have generally centred around its
effect on the vasculature. A randomized control trial of 207 patients followed up for 6 months
found that the side effects of Terazosin were similar to that of placebo, while a drop in blood
pressure was found only in uncontrolled hypertensives, but not in controlled hypertensives or
normotensive patients (Kirby 1998). Another prospective non-randomised trial of 36 patients
with a follow-up of 6 months found Terazosin and Doxazosin to be safe in elderly
hypertensives and normotensives, whereby no patients stopped medication due to its
vasodilatory effects and only a small non-significant decrease in blood pressure due to
aesthenia was noted in 3 patients who stopped medication (Kaplan 1997). In a non- systematic
review of alpha adrenoceptor blockade in the treatment of benign prostatic hyperplasia, an
estimated 6.7% of patients had vasodilatory side effects but these were rarely troublesome
enough to require cessation of treatment. Most patients in clinical trials completed their therapy
and withdrawal was frequently for reasons other than side effects or poor efficacy (Kirby,
1997). Another review article found that α1 blockers are appropriate for elderly patients
associated with hypertension and hyperlipidemia. Side effects were minor except for postural
hypotension, which decreased with gradual titration. There were no long-term metabolic side
effects nor was it affected by renal dysfunction (Cooper, 1995). In another single blind
randomised trial of 72 patients with a follow-up for 9 weeks, systolic and diastolic blood
pressure decreased significantly in the Terazosin group as compared to the Tamsulosin group,
reflecting the better safety profile of Tamsulosin (Lee, 1997). Another review by Chapple
(1998) concluded that Tamsulosin had a better or equivalent safety profile compared to
Alfuzosin which, in turn, is better than Doxazosin and Terazosin. A case-study of Terazosin
resulting in generalised cutaneous rashes that spontaneously resolved on withdrawal of
medication has been reported (Hernandez-Cano, 1998).

As for Alfuzosin, a non-systematic review found that a twice daily dose has lower side effects
compared to a thrice daily dose (Kirby, 1998). A double blind randomised trial of 256 patients
with a 12-week follow-up found that the antihypertensive effects of Alfuzosin were not
significantly different from that of Tamsulosin. However, statistically significant effects on
systolic supine blood pressure, supine and standing blood pressure were observed in the elderly
(Buzelin, 1997). Another two randomised controlled trial of Alfuzosin involving 588 patients
followed up at 1 and 3 months found that the incidence of drug withdrawal and adverse events
related to vasodilatation was similar to placebo. However, a higher incidence of asymptomatic
orthostatic hypotension was noted in the elderly and hypertensives (Buzelin, 1997). A separate
randomised controlled trial of 390 patients on Alfuzosin followed up for 12 weeks also found
that the drop out rate from side effects and vasodilatory events were similar to placebo
(Buzelin, 1997). Further, a non-controlled post marketing surveillence study on 13 389 patients
on SR Alfuzosin reported only a rate of 2.7% in vasodilatory events (Lukacs, 1996).

Prazosin has often been linked to syncope and the first dose phenomenon as reported in a non-
systematic review of alpha adrenoceptor blockade in the treatment of BPH (Kirby, 1997).
Another review article also highlighted the first dose effect and postural hypotension associated
with Prazosin (Chapple, 1998). On the other hand, a prospective study of 31 patients awaiting
TURP on Prazosin treatment, followed up for 1 to 8 weeks, noted its short-term safety
(Ogbonna, 1997). Another review article on the pharmacokinetics of Prazosin found no
evidence that it accumulates in renal failure, nor that age-related pharmacokinetic differences is
likely to be of major importance. Its first dose effect was said to be unrelated to its
pharmacokinetic profile (Vincent, 1985). However, a separate review article on Prazosin found
that initial doses of 2 mg or more was more likely to trigger off the first dose phenomenon. It
was less likely with starting doses of 1 mg or less and none was reported when diuretic was
stopped. Orthostatic hypotension in hypertensives was mild and transient (AIDS Publication
1985).

Tamsulosin, was found not to change blood pressure 1, 2, 4 and 8 hours after the first dose, in a
multicentre, double blind randomised placebo-controlled trial of 126 patients followed up for 4
weeks (Abrams, 1997). A double blind randomised controlled trial comparing Alfuzosin and
Tamsulosin in 256 patients followed up for 12 weeks found that Tamsulosin caused only an
isolated case of retrograde ejaculation (Buzelin, 1997). Another review article concluded that
Tamsulosin is the preferred treatment for symptomatic BPH over other α1 adrenoceptor
blockers in the treatment of lower urinary tract symptoms in hypertensive patients treated with
other antihypertensive agents (Narayan, 1998).

4.2.2 Five alpha reductase inhibitors

A 4 year follow up of 4 222 patients on Finasteride found that its side effect profile and
discontinuation rate similar to placebo with the exception of sexual side effects (decreased
libido, ejaculatory disorders and erectile dysfunction). Otherwise, it was safe and well tolerated
(Chapple, 1998). An observational cohort study on 14 772 patients on Finasteride for one year,
found that impotence was the most common reason for stopping treatment, but it was safe and
had good tolerability in long term therapy (Wilton, 1996). A review article also found that the
side effects of Finasteride were minor and similar to placebo except for libido, impotence and
ejaculatory disorders (Cooper, 1995). A separate review article revealed that only 2% patients
ceased treatment due to side effects (Stricker, 1995). Finasteride was found to have minimal
side effects and adverse events, which resolved with continued therapy or drug withdrawal, in
another review article (Yin, 2000)

4.2.2 Phytotherapy
A systematic review on the use of beta-sitosterol on men with symptomatic BPH found that its
withdrawal rates were similar to placebo but gastrointestinal symptoms and impotence were
higher as compared to placebo (Wilt, 1999).
Another review article on the use of saw palmetto for symptomatic BPH found that adverse
effects were rare but use in pregnant women and children was not recommended when used for
other indications (Wilt, 1998)

4.3 Cost Implications

The evaluation of the cost- effectiveness of the various treatment modalities were dependent on
the following factors:
i) Life expectancy of the patient.
ii) Severity of symptoms at presentation.

4.3.1 Surgical vs. Medical Management of BPH

Generally, studies reviewed indicated that men with mild to moderate symptoms were the best
candidates for medical treatment, while surgery is usually indicated for patients with severe
symptoms (Otten, 1996; Cockrum et al, 1997). All other parameters being equal, surgery
appears to be more cost effective at younger patient ages, while medical management has a
cost advantage at older ages (Thomas et al. 1996). Finasteride was found to be more costly
than TURP if the patient’s lifespan was over 14 years (Effective Health Care, 1995).

4.3.2 Medical Management of BPH

Alpha Blockers
A randomized controlled trial involving 2084 men followed up for 1 year found that Terazosin
was more cost-effective when compared to placebo (Hillman et al. 1996).

A systematic review of 9 randomized control trials (Effective Health Care, 1995) demonstrated
that Prazosin to be more cost-effective than Terazosin. A study by Cockrum et al (1997)
demonstrated that alpha- blockers (Prazosin > Terazosin > Doxazosin) were more cost-
effective than Finasteride.

5 α Reductase Inhibitors (Finasteride)

A systematic review of 9 randomized control trials (Effective Health Care, 1995) found
Finasteride was more costly than all the alpha-blockers. A health technology assessment by the
Canadian Coordinating Office for Health Technology Assessment Ottawa (1995), involving
males with BPH aged > 60 years, found that the cost- effectiveness of initiating Finasteride
over Watchful Waiting (WW) and TURP was dependent on the choice of time horizon -
Finasteride was more cost-effective than WW if the time horizon was less than 4 years, while it
was more cost-effective than TURP if the time horizon was less than 14 years. In a review,
(Otten, 1996), two randomized controlled trials comparing Finasteride with placebo reported
that Finasteride produced more Quality Adjusted Life Years (QALYs) than surgery in men
suffering from mild symptoms and whose life expectancy was 14 years or less. For patients
with moderate symptoms and a life expectancy of 3 years or less, Finasteride produced a better
quality of life than WW.

Finasteride demonstrated more cost offsets when compared with WW and Terazosin over 2
years. Finasteride also appeared to be more economical in men with higher Prostatic Specific
Antigen (PSA) levels (Albertsen et al. 1999). A study by Lowe et al., (1995) concluded that the
most expensive intervention was surgery, followed by Finasteride and Terazosin at 24 months
of therapy.

5. CONCLUSION

There is sufficient evidence to conclude that alpha blockers and five alpha reductase inhibitors
are effective to treat moderate symptoms of BPH. Alpha blockers are safe for normotensive
and controlled hypertensive elderly patients, with Tamsulosin having the least side effects
compared to other α1 adrenoceptor blockers. Five alpha reductase inhibitors have minimal
sexual related side effects such as decreased libido, ejaculatory disorders, erectile dysfunction
and impotence, but is otherwise safe and well tolerated. With respect to cost implications, there
is sufficient evidence to support medical management of BPH in older patients, since it is only
cost effective for short time horizons. There is sufficient evidence to suggest that alpha-
blockers are more cost- effective than alpha reductase inhibitors.

There is insufficient evidence to support the effectiveness and safety of phytotherapy.

6. RECOMMENDATION

Medical management is recommended for treatment of elderly patients with mild to moderate
BPH.
7. REFERENCES

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and terazosin in increasing doses

22. Lowe FC; Mc Daniel RL Chiel JJ, Hillman AL. Economic modeling to assess the
costs of treatment with finasteride, terazosin and transurethral resection of the
prostate for men with moderate to severe symptoms of benign prostatic
hyperplasia. Urology 1995 Oct; 46(4): 477-83.

23. Lukacs B et. al Safety profile of 3 months’ therapy with alfuzosin in 13389
patients suffering from Benign Prostatic Hypertrophy. European Urology 1996;
29: 29-35

24. Narayan P; Man't Veld AJ In. Clinical pharmacology of modern antihypertensive

agents and their interaction with alpha-adrenoceptor antagonists (LUTS and
HPT: Controversies in treatment. BJU 1998 Mar; 81 (Supp. 1): 6-16
25. Ogbonna FMCS et. al. Alpha-receptor blockade for benign prostatic hyperplasia:
uses and problems in a developing country

26. Ophelia QP Yin Finasteride: Drug Profile. Medical Progress February 2000 pp
37-40

27. Otten N. Finasteride: clinical and economic impacts. Technology overview:

pharmaceuticals, Canadian Coordinating Office of Health Technology
Assessment (CCOHTA), Canada.1996, Issue 2.0, 1-8.

28. Philip D. Stricker. Drug treatment of benign prostatic hypertrophy . Australian

Prescriber 1995; 18(2):30-32

29. Quek KF et. al The psychological effects of treatments for LUTS. BJU October
2000: Vol 86(6) pp 630-633

30. The ALLHAT Officers and Co-ordinators for the ALLHAT Collaborative
Research Group. Major Cardiovascular Events in Hypertensive Patients
Randomized to Doxazosin vs Chlorthalidone. JAMA, 2000 April 19; 283(15)

31. The Cost- Effectiveness Of Terazosin And Placebo In The Treatment Of

Moderate To Severe Benign Prostatic Hyperplasia. Urology, 1996, 47(2), 169-
178.

32. Thomas N. Chirikos and Edgar Sanford. Cost Consequences Of Surveillance,

Medical Management Or Surgery For Benign Prostatic Hyperplasia. Journal of
Urology Vol. 155, 1311-1316, April 1996.

33. Wilt T; Macdonald R; Ishani. A beta-sitosterol for the treatment of benign

prostatic hyperplasia: a systematic review. BJU June 1999 pp 976-983

34. Wilton, L. et al . The safety of finasteride used in benign prostatic hypertrophy: a

non-interventional observational cohort study in 14772 patients/ BJU 1996 Sept
78(3):379-384
 8. EVIDENCE TABLE
MEDICAL MANAGEMENT OF BPH - COST BENEFIT/ EFFECTIVENESS

No. Author/ Title/ Journal Study Design, Sample Size, Outcome & Characteristics Comments
Follow- up Grade of Evidence

1. Hillman A L, Schwartz J S, William M K, - Prospective, randomized Terazosin- treated patients had improvement in Good -2
Peskin E, Roehrborn C G, Oesterling J E, double-blind, placebo- symptomatology on the 3 AUA indices (AUA symptom A short time horizon
Mason M F, Maurath C J, Deverka P A, controlled trial score, Bother score and Quality- of Life score). is a limitation of this
Padley R J. - Patients were randomized study.
The Cost- Effectiveness Of Terazosin And at 15 regional centres and The costs of health care resource utilization were similar for
Placebo In The Treatment Of Moderate To 141 satellite centres to men treated with terazosin and those receiving placebo.
Severe Benign Prostatic Hyperplasia. ensure a sample size of
2084 men (1031- placebo,
Urology, 1996, 47(2), 169-178. 1053-terazosin).
Follow up 1 year

2. Benign Prostatic Hyperplasia. Systematic review of Watchful waiting is likely to be the least cost option for Good - 1
randomized control trials. men with mild or moderate Adequate time
Effective Health care Finasteride is more costly than TURP if the patient’s horizon, cost and
December 1995 Volume 2 Number 2, lifespan is over 14 years. severity of symptoms
ISSN: 0965-02888. Drug therapy costs around $(Pounds) 325 per man-year for have been addressed.
Finasteride, $(Pounds) 347 for Terazosin and $(Pounds) 60
for Prazosin.
All 3 alpha-blockers are equally effective.

3. Eri L M, Tveter K J. - Men with moderate symptoms of BPH are the best Original paper not
Treatment of benign prostatic hyperplasia: candidates for medical treatment, while surgery is usually obtained.
indicated for patients with severe symptoms.
a pharmacoeconomic perspective. Finasteride is most effective in men with large prostates (>
40 mm).
Alpha-blockers work in men with small or large prostates,
Drugs & Aging, 1997, 10(2), 107-118.
and their rapid onset of action facilitates the identification
of responders.
No. Author/ Title/ Journal Study Design, Sample Size, Outcome & Characteristics Comments
Follow- up Grade of Evidence

Otten N.Finasteride: clinical and

4. - Two randomized For patients with moderate symptoms and a life expectancy Good - 1
economic impacts. controlled trials of of 3 years or less, finasteride produced a better quality of
finasteride versus placebo life than watchful waiting. No comparison made
in men with BPH. Finasteride produced more QALYs than surgery, for men with alpha blockers
Technology overview: pharmaceuticals,
suffering from mild symptoms and whose life expectancy
- The time horizon for the was 14 years or less.
1996, Issue 2.0, 1-8.
analysis was from 1 to 15 For men with severe symptoms, surgery produced a better
years. quality of life.
Canadian Coordinating Office of Health For moderate symptoms, watchful waiting produced a
better quality of life than surgery.
Technology Assessment (CCOHTA), The choice of Finasteride is dependent on 2 factors: life
expectancy and the severity of symptoms.
Canada.

Cost-effectiveness and cost-utility analyses

5. - Study population: Males, Cost-effectiveness of initiating treatment for BPH with It was assumed that if
of finasteride therapy for the treatment of aged above 60 and finasteride, rather than WW or TURP, was dependent on an intervention were
experiencing symptoms of the choice of time horizon. effective, then it
benign prostatic hyperplasia. BPH. would remain
- Costs, effects and quality- Finasteride was more cost-effective than WW if the time effective.
adjusted-life-years horizon was less than 4 years; finasteride was more cost-
(QALYs) were estimated effective than TURP if the time horizon was less than 14
over time horizons years.
Canadian Coordinating Office for Health ranging from 2- 15 years.

Technology Assessment Ottawa, Ontario:

Canadian Coordinating Office for Health

Technology Assessment, 1995.

No. Author/ Title/ Journal Study Design, Sample Size, Outcome & Characteristics Comments
Follow- up Grade of Evidence

Baladi J F, Menon D, Otten N

6. To assess the cost- Treating patients with moderate symptoms using finasteride Original paper not
effectiveness of using rather than TURPP leads to savings of Can$32,000 over 4 obtained.
An economic evaluation of finasteride for
finasteride versus TURP and years.
watchful waiting (WW) in the The incremental cost per QALY gained in using finasteride
treatment of benign prostatic hyperplasia.
treatment of older men with rather than WW, for a 4-year time horizon was can$19,000.
BPH. Sensitivity analysis showed that the sensitive parameters
PharmacoEconomics, 1996, 9(5), 443-454. were effectiveness of WW and time horizon of treatment

H. Lohgan Holtgrewe
7. - Review article on the Watchful waiting: US$1,162 (a) US$640 (b) The costs depicted
guidelines issued by the Finasteride are enormously
Economic Issues And The Management Of
Agency for Health Care US$1,326 (a) influenced by
Policy and Research US$788 (b) treatment failure
Benign Prostatic Hyperplasia
(AHCPR) for the Alpha- blocker rates.
diagnosis and US$1,395 (a)
Urology 46 (Supplement 3A), 1995, 23-25. management of BPH in US$845 (b)
the United States. Balloon Dilation
- Clinical practice US$3,723 (a)
guidelines were applied US$543 (b)
only to men > 55 years TURP
with classical symptoms US$8,606 (a)
of prostatism with no US$360 (b)
confounding co-
morbidity. Open prostatectomy

US$12,788 (a)
US$69 (b)
Key:
(a): Cost for primary Treatment and 1 Year Follow-
up
(b) Cost for Second Year of Treatment after Primary
Treatment
No. Author/ Title/ Journal Study Design, Sample Size, Outcome & Characteristics Comments
Follow- up Grade of Evidence

Thomas N. Chirikos and Edgar Sanford

8. Synthetic cohort models were Cost- effectiveness of each type of BPH therapy differs by Original paper not
Cost Consequences Of Surveillance, constructed to follow men at the age of the patient at which it is first initiated. obtained.
different ages “analytically” All other parameters being equal, surgery appears to be
Medical Management Or Surgery For for specific intervals and to more cost effective at younger patient ages, while medical
calculate the cumulative health management has a cost advantage at older ages.
Benign Prostatic Hyperplasia. care costs for alternative BPH
treatment.

The Journal of Urology Vol. 155, 1311-

1316, April 1996.

Cockrum PC, Finder SF, Riess AJ, Potyk

9. - Review article Men with moderate symptoms are the best candidates for Original paper not
RP. - Therapies compared were medical treatment, while surgery is usually indicated for obtained.
Finasteride and alpha- patients with severe symptoms. Pharmacological therapy
A pharmacoeconomic analysis of patients blockade (doxazosin, was more cost- effective than surgical intervention, and
prazosin and terazosin). alpha-blockers (Prazosin> Terazosin> Doxazosin) were
with symptoms of benign prostatic more cost effective than Finasteride.

hyperplasia.

Pharmacoeconomics 1997 Jun; 11(6): 550-

65.
 Albertsen PC, Pellisier JM, Lowe FC,
10. Finasteride shows cost offsets compared with watchful No original paper
Girman CJ, Roehrborn CG. waiting and cost savings compared with terazosin over 2 obtained.
years.
Economic analysis of finasteride: a model-

based approach using data from the Finasteride appears to be more economical in men with
higher PSA levels.
PROSCAR Long- Term Efficacy and Safety

Study.

Clinical Therapeutics 1999 Jun; 21(6):

1006-24.
No. Author/ Title/ Journal Study Design, Sample Size, Outcome & Characteristics Comments
Follow- up Grade of Evidence

Lowe FC, McDaniel RL, Chmiel JJ,

11. - The most expensive intervention was surgery, followed by Original article not
Hillman AL. finasteride and terazosin at 24 months of therapy. obtained.
Duration of symptom improvement was comparable for the
Economic modeling to assess the costs of three treatments.

treatment with finasteride, terazosin and

transurethral resection of the prostate for

men with moderate to severe symptoms of

benign prostatic hyperplasia.

Urology 1995 Oct; 46(4): 477-83.

 SAFETY

No. Author/ Title/ Journal Study Design, Sample Size, Outcome & Characteristics Comments
Follow- up Grade of Evidence

1. The ALLHAT Officers and Co-ordinators Clinical trial on the use of Doxazosin treated group has a significantly higher Poor-8
for the ALLHAT Collaborative Research doxazosin vs chlorthalidone as incidence of cardiac failure
Group/ Major Cardiovascular Events in a antihypertensive.
Hypertensive Patients Randomized to
Doxazosin vs Chlorthalidone N= 42448

JAMA, 2000 April 19; 283(15) F/U: since 1994

2. Kirby, R.S. Double blind randomised Side effects profile similar to placebo. Good - 2
Terazosin in benign prostatic hyperplasia: controlled trial Dizziness: 0% (placebo) 1.20% drop-out in the
effects on blood pressure in normotensive 3%(terazosin) initial single blind
and hypertensive men N= 207 patients Headache: 1%(placebo) selection study: not
2%(terazosin) analysed in detail in
F/U: 6 months somnolence:0%(placebo) the study.
BJU Sept 1998, l82(3):373-379) 2%(terazosin) 2. Sample is bias due
Clinically significant decrease in BP in untreated and to the initial selection
uncontrolled hypertensives with BPH but not in the study
normotensive and controlled hypertensives group.
Clinically significant decrease in SBP and DBP in the
normotensive group.

3. Hernandez-Cano et al Single case report Generalised cutaneous rash 3 days after starting treatment Poor - 9
Severe cutaneous reaction due to terazosin on terazosin.
Resolved with drug withdrawal
Lancet 1998 July; 352(9123): 202-20
No. Author/ Title/ Journal Study Design, Sample Size, Outcome & Characteristics Comments
Follow- up Grade of Evidence

5. Kirby, R.S.; Pool, J.L Non systematic review with TURP complications: 2 - Good
Alpha adrenoceptor blockade in the 63 references Intra-op: 6.9% No major side-effects
treatment of benign prostatic htperplasia: Post-op: 18% as opposed to TURP
past, present and future POM(30d): 0.23%
All alpha blockers (prazosin, doxazosin, alfuzosin,
BJU 1997 Oct, 80(4):521-532 terazosin, tamsulosin) are of similar efficacy.
Side effects profile due to different pharmacokinetics.
Prazosin: syncope and first dose effect.
Alfuzosin: lower side effects ( twice daily dose better than
thrice daily)
Tamsulosin: Dizziness 5%
Doxazosin: Dizziness 3%, fatigue 2%, headache 1.2%,
oedema 1.3%
Premature discontinuation:
17% due to adverse events
9% due to insufficient clinical response.
Terazosin: Dizziness 6.7%, aesthenia 3.8%, somnolence 2%
Premature discontinuation:
19% due to adverse events
11% due to insufficient clinical response.
ED side effects:
Doxazosin: 1.3%
Placebo: 3.8%
Beta-blockers: 4.6%
Ace-inhibitors:6.1%
Calcium channel antagonist: 9.0%
Favourable doxazosin side effects:
Little or no effects on normotensives
Beneficial BP effect for hypertensives
Improved serum lipid profile
Increased fibrinolysis, inhibition of platelet aggregation,
decreased cardiac hypertrophy, increased insulin
hypersensitivity.
Syncopal attacks: Doxazosin similar to placebo
 No. Author/ Title/ Journal Study Design, Sample Size, Outcome & Characteristics Comments
Follow- up Grade of Evidence

6. Abrams, P et al Multicentre, double blind Report of at least one adverse event: Good - 2
A dose-ranging study of the efficacy and randomised placebo-controlled 29% placebo
safety of Tamsulosin, the first prostate- 23% tamsulosin 0.2mg
selective alpha 1A- adrenoceptor N=126 patients 27% tamsulosin 0.4mg
antagonist, in patients with benign 36% tamsulosin 0.6mg
prostatic obstruction (symptomatic BPH F/U: 4 weeks No statistical significant change in BP 1,2 4 and 8 hours
after first dose.
BJU. 1997 Oct, 80(4) :587-596 Mean age group: 65years old

7. Buzelin, J.M. et al Double blind randomised 132 patients on tamsulosin Good - 2

Comparison of tamsulosin with alfuzosin multicentre, parralel group 124 patients on alfuzosin The group of
in the treatment of patients with LUTS trial 233 completed trial patients above 75
suggestive of BOO (symptomatic BPH) 14 withdrew due to adverse events years of age is small
N=256 patients Alfuzosin:
BJU 1997Oct; 80(4):597-605) Adverse events associated with antihypertensive effects not
F/U: 12 weeks significantly different from tamsulosin
Statistical significant effect on systolic supine BP, standing
and supine diastolic BP and this is more apparent in the
elderly.
Tamsulosin:
Isolated report of retrograde ejaculation

8. Lee, E., Lee, C Single blind randomised trial Systolic and diastolic BP decreased significantly in the Good - 3
Clinical comparison of selective and non- trazosin group as compared to the tamsulosin group High withdrawal
selective alpha 1A-adrenoceptor N= 72 patients 98 patients started the trial but 2 patients withdrew. rate.
antagonists in benign prostatic (10 in the tamsulosin group and 16 in the terazosin group, Tamsulosin dose
hyperplasia: studies on tamsulosin and F/ U: 9 weeks of which 2 were due to adverse events) used was 0.2mg.
terazosin in increasing doses Adverse reaction: (fixed dose) whereas
Terazosin 18 terazosin was used
Tamsulosin 1 on an escalating
Tamsulosin has better safety profile. dose.
Dizziness 1.2% due to a drop in BP Tamsulosin dose
used might not be in
the optimal level.
No. Author/ Title/ Journal Study Design, Sample Size, Outcome & Characteristics Comments
Follow- up
Grade of Evidence
9. J.M. Buzelin et al Two double blind randomised 43% of patients had concomittant cardiovascular disease Good - 2
Clinical Uroselectivity: evidence from controlled studies and/ or on antihypertensive medication
patients treated with slow-release Incidence of withdrawal:
alfuzosin for symptomatic benign N= 588 patients 3.4% c.f. 5.7% for placebo
prostatic obstruction/ Adverse events related to vasodilatation similar to placebo:
F/U: 1 and 3 months 2.7%
BJU 1997 June;- 79(6): 898-904 Effects on supine minimal.
For the elderly and hypertensives:
Higher incidence of asymptomatic orthostatic hypertension
compared with placebo

10. Ogbonna, FMCS et al Prospective follow-up of 31 62% benefitted. Poor - 8

Alpha-receptor blockade for benign patients awaiting: TURP Only short term safety noted No control group
prostatic hyperplasia: uses and problems followed up for 1 to 8 weeks Only short term
in a developing country follow-up
Selected group of
patients awaiting
TURP
11. Quek K.F., et al Psychosocial assessment on Patients before TURP were significantly more worried and Fair - 4
The psychological effects of treatments 123 patients on medical depressed and psychiatrically more morbid than those Both groups being
for LUT/ treatment and 52 patients with before medical treatment. evaluated are at
TURP at baseline and 3 different starting
BJU October 2000: Vol 86(6) pp 630- months after treatment points.
633)
12. Wilt, T; Macdonald, R.; Ishani, Systematic review on the use Withdrawal rates: Good - 3
A beta-sitosterol for the treatment of of beta-sitosterol on men with 7.8% c.f. 8% for placebo (n.s.) Different types of
benign prostatic hyperplasia: a symptomatic BPH (through GIT symptoms: beta-sitosterol were
systematic review Medline Search 1966-1998, 1.6% c.f. 0 % forPlacebo used.
EMBAS and Cochrane Impotence: Only short term
BJU June 1999 pp 976-983 Library). 0.5% c.f. 0% for placebo. follow-up
4 double blind studies were
relevant.
F/U: 4-26 weeks
No. Author/ Title/ Journal Study Design, Sample Size, Outcome & Characteristics Comments
Follow- up
Grade of Evidence
13. Klepser, Teresa Bailey et al. Review article on various Adverse effects: rare headache Poor - 8
Unsafe and potentially safe herbal herbal therapy including saw Nausea and upset stomach Type of saw
therapies palmetto for symptomatic Use in pregnant women and children not recommended palmetto not
American Journal of Health-System BPH standardised
Pharmacy 1999 Jan 15; 125-138 Large RCTs still not
avaialble
Short term follow-
up
14. Chapple, C R Review article with 109 4 year follow up of 4222 patients on finasteride: Good - 2
Pharmacotherapy for benign prostatic references side effect profile and discontinuation rate similar to
hyperplasia- the potential for alpha1- placebo with the exception of sexual side effects:
adrenoceptor subtype specific treatment decreased libido
(LUTS and HPT: controversies in ejaculatory disorders
treatment)/ erectile dysfunction
Otherwise safe and well tolerated
BJU March 1998 Vol 81 Supp. 1 pp 34- Phenoxybenzamine: 30% had side effects and also
47 mutagenic
Prazosin: first dose effect and postural hypotension
Side effect profile:
Tamsulosin better or equivalent to alfuzosin which in turn
is better than Doxazosin/ Terazosin

15. Narayan, P. ; Man’t Veld, A.J. IN Review article with 78 Tamsulosin the preferred treatment for symptomatic BPH Good - 2
Clinical pharmacology of modern references over other alpha1 adrenoceptor blockers in the treatment of
antihypertensive agents and their LUTS in patients with HPT on other antihypertensive
interaction with alpha-adrenoceptor agent.
antagonists (LUTS and HPT:
Controversies in treatment

BJU 1998 Mar; 81 (Supp. 1): 6-16

No. Author/ Title/ Journal Study Design, Sample Size, Outcome & Characteristics Comments
Follow- up
Grade of Evidence
16. Wilton, L. et al Observational, cohort study on Finasteride was effective in 60% of patients Fair - 6
The safety of finasteride used in benign 14772 patients who were on Impotence/ Ejaculatory failure: 2.1% Free from selection
prostatic hypertrophy: a non- finasteride for at least 1 year Decreased libido: 1% bias
interventional observational cohort study Gynaecomastia/ related conditions: 0.4% No randomisation
in 14772 patients/ Impotence: most frequent reason for stopping treatment/ 63% response rate
most common adverse reaction GP practice follow-
BJU 1996 Sept 78(3):379-384 Safe and good tolerance in long term therapy. up/ hospital not
included

17. James W. Cooper, Robert W. Piepho Review article of medline Alpha-1 blockers: appropriate for elderly patients Poor - 8
Cost-effective management of benign search of relevant articles associated with hypertension/ hyperlipidaemia
prostatic hyperplasia/ Side effects minor except for postural hypotension but
decreased with gradual titration
www.medscape.com/SCP/DBT/1995/v07 No long term metabolic side effects
.n08/d152.cooper/d152.cooper.html Not affected by renal dysfunction
Terazosin: 13% withdrew due to side effects
Finasteride: Minor and similar to placebo except for libido,
impotence and ejaculatory disorders
18. John Vincent, Peter A. Meredith, John L. Clinical pharmacokinetics of No evidence to suggest that prazosin accumulates in renal Poor - 8
Reid, Henry L. Elliot and Peter C. Rubin prazosin failure.
Pharmacokinetics of Prazosin- Age related pharmacokinetic differences unlikely to be of
major importance.
First dose effect not explained pharmacokinetically
Clinical Pharmacokinetics 1985; 10: 144-
154
19. Prazosin/ Minipress: A summary of A summary on prazosin after Initial doses greater than 2mg more likely to trigger off Poor - 9
fifteen years of clinical experience its use for 15 years ‘first dose phenomenon. Data was on its
Less likely with starting dose of 1 mg or less. used in hypertensive
None reported when diuretic was stopped patients
Orthostatic hypotension in hypertensives mild and transient.
Other side effects:
Headache: 7.8% ; Drowsiness: 7.6%;
Lack of energy: 6.9%; Weakness: 6.5%
Palpitations: 5.3%; Nausea: 4.9%
 No. Author/ Title/ Journal Study Design, Sample Size, Outcome & Characteristics Comments
Follow- up
Grade of Evidence
20. Philip D. Stricker Review article Finasteride: Poor - 9
Drug treatment of benign prostatic Only 2% ceased treatment due to side effects
hypertrophy

Australian Prescriber 1995; 18(2):30-32

21. Ophelia QP Yin Review article Side effects minimal. Poor - 9

Finasteride: Drug Profile Adverse events may resolve with continued therapy or drug
withdrawal
Medical Progress February 2000 pp 37-40

22. J.M. Buzelin et al Randomised controlled trial Drop-out rate from side effects: Good - 2
Efficacy and safety of Sustained-Release 4.6% (SR Alfuzosin)
Alfuzosin 5 mg in patients with Benign N= 390 patients 7.1%(Placebo)
Prostatic Hyperplasia Vasodilatory events(3.1%) similar to placebo(3.6%)
F/U: 12 weeks Drop in supine BP ,/= 5mmHg
European Urology 1997: 31: 190-198

23. B. Lukacs et al Non-controlled post marketing Drop-out rate 10.3% Fair - 6

Safety profile of 3 months’ therapy with surveilllence studies on 13389 3.7% for intolerance
alfuzosin in 13389 patients suffering from patients on SR alfuzosin 2.7% for vasodilatory events:-
Benign Prostatic Hypertrophy vertigo/dizziness (1.4%)
headache (0.4%)
European Urology 1996; 29: 29-35 malaise (0.6%)
hypotension (0.4%)
 Appendix 1
INTERNATIONAL PROSTATE SYMPTOM SCORE
Almost always
Never Less than Less than half About half the More than half 5 Your Score
once in five the time time the time
0 1 2 3 4

Incomplete emptying
Over the last month how often have you had a sensation of not
emptying your bladder completely after you finish urinating?

Frequency
Over the past month how often have you had to urinate again less than
two hours after finishing?

Intermittency
Over the past month, how often have you stopped and started
again several times when you urinated

Urgency
Over the past month how often have you found it difficult to hold
your urine

Weak Stream
Over the past month how often have you had a weak urinary
stream

Straining
Over the last month how often have you had to push or strain to
begin urination?

Nocturia
Over the past month how many times did you most typically
getup to urinate from time you went to bed at night until the time
you got up in the morning
Quality of Life due to Urinary Symptoms

If you were to spend the rest of your life with your urinary condition

as it is now, how would feel about that.

 Appendix 2

LEVELS OF EVIDENCE SCALE

Level Strength of Evidence Study Design
1 Good Meta-analysis of RCT, Systematic reviews.

2 Good Large sample of RCT

3 Good to fair Small sample of RCT

4 Non-randomised controlled prospective

trial
5 Fair Non-randomised controlled prospective
trial with historical control

6 Fair Cohort studies

7 Poor Case-control studies

8 Poor Non-controlled clinical series, descriptive

studies multi-centre

9 Poor Expert committees, consensus, case

reports, anecdotes

SOURCE: ADAPTED FROM CATALONIAN AGENCY FOR HEALTH TECHNOLOGY ASSESSMENT

(CAHTA), SPAIN
 THE FOLLOWING HTA REPORTS ARE AVAILABLE ON REQUEST:

REPORT YEAR
1. LOW TEMPERATURE STERILISATION 1998
2. DRY CHEMISTRY 1998
3. DRY LASER IMAGE PROCESSING 1998
4. ROUTINE SKULL RADIOGRAPHS IN HEAD INJURY PATIENTS 2002
5. STROKE REHABILITATION 2002
6. MEDICAL MANAGEMENT OF SYMPTOMATIC BENIGN PROSTATIC 2002
HYPERPLASIA