Benign nocturia and often have negative impact on

 Benign Prostatic
Hyperplasia (BPH), is an extremely common condition, espically among older man,
which refers to the proliferation of smooth muscles and epithelial cells within
the prostatic transition zone, resulting in an increase in size of prostate
gland.1 Prostate tissue has two elements: a glandular element which is
composed of secretory ducts and acini; and a stromal element which is composed
primarily of collagen and smooth muscle. BPH progression has two phases in
which first phase include increase in BPH nodules in the periurethral zone and
second phase include significant increase in size of glandular nodules.2,3
BPH results in the compression of urethra and may present as Lower Urinary
Tract Symptoms (LUTS).4 LUTS include urinary frequency, urgency, weak stream
and nocturia and often have negative impact on Quality Of Life (QOL), commonly
in elderly man. 5. In severe cases patients may develop urinary retention,
kidney blockage (hydronephrosis), or renal failure.6.

The
excat etiology for BPH is not known, but the hypothesis has been proposed that
BPH may be caused from a “reawakening” of embryonic induction processes in
adulthood because of the similarity between BPH and the embryonic morphogenesis
of prostate. 1,7

According
to the analysis of prostate needle biopsy, the most common benign lesions
observed was BPH which is followed by BPH with chronic prostatitis and chronic
prostatitis alone. Most of the benign lesions was seen between the age of 60-79
years, and malignant lesions between the age of 70-79 years. 8,9,10,11

The
prevalence of BPH increases with age. The histological prevalence of BPH has
been observed as 8%, 50% and 80% in 4th, 6th and 9th
decades of life, respectively.12 Prostatic Hyperplasia is associated with
numbers of genetic factors. The growth of prostate gland is controlled by
circulating androgens and intracellular steroid signaling pathways mediated
through Androgen Receptor (AR). Testosterone (major androgen in males) is
converted to Dihydrotestosterone (DHT) by hormone 5-? reductase in Prostatic
cells. DHT is a potent stimulator of prostate growth, and plays a central role
in pathogenesis of BPH.13, 14,15 There is no variation in incidence of
histological BPH (diagnosed via biopsy or autopsy) across all racial groups,
but the incidence of clinical BPH (diagnosed via symptoms and clinical
examinations) is found higher among African and Americans than in Asian. Diet
is a potential modifiable risk factor. Asian populations are associated with
soya-rich diets, which are high in phyto-estrogens (eg: genistenin), which have
an inhibitory effect on BPH. Increased total energy intake, milk and dairy
products, red meat, cereals, bread, starch increases the risk for BPH whereas
fruits, vegetables (particularly carotenoids), Vitamin D and Vitamin A
decreases the risk.16,17 Other modifiable risk factors may include
Hypertension, serum lipids and lipoproteins, and smoking.18

The
prevalence of moderate to severe LUTS is high, with 45% in the age group above
70 years.19,20

Pharmacological
therapy for BPH-associated LUTS helps to improve the Quality of Life (QOL) ,
especially in elderly men.3,21 Five classes of drugs are generally used for
BPH-associated LUTS. ?-adrenergic blockers (Abs), 5-? reductase inhibitors
(5-ARIs), antimuscarinics, phosphodiesterase-5 inhibitors (PDE-5) and
phytotherapeutics. Among these classes of drugs ?-adrenergic blockers and 5-?
reductase inhibitors, either singly or in combination therapy to control
symptoms and disease progression.22,23

?-adrenergic
blockers relaxes the smooth muscles of bladder neck and the prostate hence
improving the symptoms and flow. The most commonly used ?—blockers: Alfuzosin,
Tamsulosin, Doxazosin, Terazosin have equal clinical effectiveness. The most
common side effects of ABs are headache, dizziness and postural hypotension. In
addition, sexual side effects like erectile dysfunction may also be seen in
some patients. Patients may discontinue the use of drug because of side effects.16,24,25

5-ARIs
inhibits 5-? reductase, which converts 
Testosterone to DHT, a potent stimulator for prostate growth.
Finasteride, Dutasteride are the commonly used drugs of this class. Generally,
these drugs are well tolerated, but adverse effects like impotence, ejaculation
disorders, rashes and breast enlargement (gynecomastia) has been reported in
few patients.26,27

Combination
therapy (CT) of Abs and 5-ARIs have been found to be beneficial than
monotherapy.28 The benefit is greatest in patients with large prostates,
where ?-blockers relaxes the smooth muscle of prostate and 5-ARIs shrinks the
prostate.6

Antimuscarianic
agents decreases the contractile response in patients with overactive bladder
(OAB). In BPH/LUTS patient, with no evidence of bladder outlet obstruction
(BOO), it is appropriate to treat them with antimuscarianic agents; if
predominant symptoms are those of OAB.29. Multiple studies have shown that
antimuscarianic therapy alone or in combination with ?1-receptor
antagonists improves OAB symptoms in men with or without BOO.5

PDE-5
inhibitors for the treatment of BPH has not been clearly understood, but it has
been proposed that, various PDE isoenzymes are expressed in the prostate and
there are few clues which shows unspecific PDE inhibition can relax human
prostate tissue.30

Saw
Palmetto or Dwarf American Palm plant is used extensively by men in Europe for
treatment of their BPH symptoms.16

The
adherence, or compliance, of patients to a prescribed medication is defined as
the extent to which a person’s attitude in terms of taking medication coincides
with medical advice he receives. Adherence or Compliance to a drug regimen can
be divided into: Primary non-compliance, For example, when one receives a
prescription, but doesn’t have it made up at pharmacy. Secondary non-compliance
includes forgetting one or more doses of pescribed medication, taking
medication at wrong time, taking incorrect doses of pescribed medication, or
altogether stopping the medication.31 In patients with BPH, decision to
adhere to pharmacological treatment is primarily based on the patient’s
perception of bother due to LUTS and its impact on QOL. Patient’s decision to
initiate, continue or abandon treatment depends on the patient’s perspective
towards BPH and it’s management.32  Different
studies have presented evidences that adherence is inversely associated with
the complexity of drug regimen. 19,33