Management of symptomatic BPH in Italy : Who is treated and how?

OBJECTIVE: To investigate the management of symptomatic benign prostatic hyperplasia (BPH) in Italy. METHODS: Information on diagnosis, medical and surgical treatment was obtained from two different questionnaires independently mailed to urological centers in Italy. Data on drug treatments were obtained from a national database. General practitioner (GP) clinical practice patterns were obtained from a panel discussion between general practitioners and urologists. RESULTS: First line medical treatment is currently undertaken by GPs more often and to a smaller extent by urologists to whom patients can self-refer. Primary care diagnostic algorithm consists of patient's interview, physical rectal examination and urinalysis. The main reason for referral of a BPH patient to the urologist by GPs appears to be an unsatisfactory outcome of first line medical therapy. Examination of the suprapubic area plus rectal examination is always performed by urologists during physical examination while evaluation of motor and sensory function is carried out in 28% of patients only. Voiding diary and I-PSS score are currently used by 17 and 65% of urologists, respectively. Urinalysis, plasma creatinine and prostate specific antigen (PSA) are used in 100, 94 and 89% of cases, respectively. Ninety-four percent of urologists use uroflowmetry with evaluation of post voiding residual by ultrasound. Pressure-flow studies are used in selected cases by 89% of urologists. Ultrasound imaging of the kidney, bladder and prostate transrectal ultrasound (TRUS) is reported as current practice in 79, 71 and 53% of questionnaires, respectively. Over six million medical consultations with prescriptions for BPH were carried out in 1998 accounting for 190, 600,000 drug treatment days. Prescriptions for 5alpha-reductase inhibitors accounted for 71,400,000 days of treatment, alpha-blockers for 104,000,000 and plant extracts for 15,300,000 days. In 24 to 28% of cases more than one drug was prescribed. Indications for invasive treatment rely on symptoms (98%), presence of BPH complications (90%), flowmetry (65%), residual urine (50%), prostate volume (40%) and urodynamics (20%). About 10% of patients consulting the outpatient clinics were allocated to watchful waiting, 50% received pharmacological treatment and 40% invasive treatment. Analysis of invasive treatment options resulted in 62% of patients receiving transurethral resection of the prostate (TURP), 29% open prostatectomy and the remaining 9% received various forms of minimally invasive treatments. Patients were most commonly followed up for 3 months with 62% of patients followed up at one year post-operatively and then yearly. CONCLUSIONS: Our survey suggests that the current clinical practice of primary and secondary care physicians is in line with the recommendations of the IVth International Consultation on BPH. However, Italian urologists seem to use less frequently symptom scores and voiding diaries than recommended. It seems that open surgery is more frequently used in Italy than in other European countries. Minimally invasive treatments remain a very small portion of interventions for the management of BPH in Italy. Fifty-five percent of patient days of treatment are alpha-blockers, 37% is finasteride. The share of alpha-blockers has dramatically grown with the introduction of the first prostate-selective agent, tamsulosin.