NATURAL HISTORY OF BENIGN PROSTATIC HYPERTROPHY AND ACUTE URINARY RETENTION*

JOHN

D. BIRKHOFF,

A. ROGER

M.D.

WIEDERHORN,

MARY

L. HAMILTON,

HANS

H. ZINSSER,

M.D.

R.N. M.D.+

From the Department of Urology, Columbia University of Physicians and Surgeons, New York, New York

College

ABSTRACT - Twenty-six patients with prostatism due to benign prostatic hypertrophy were evaluated prospectively every three to six months for three years. Using both subjective and objective criteria signijcant deterioration was demonstrated. The rate of deterioration appeared independent of prostatic size. In the individual patient progression was variable. More than half of the patients were unchanged or improved after two years. Acute urinary retention appeared independent of the degree of prostatism and therefore unpredictable. The methods can be used to evaluate medical treatments of benign prostatic hypertrophy.

Fifty per cent of men over age sixty have histologic evidence of benign prostatic hypertrophy, and 10 per cent of men age forty will eventually require prostatic surgery.’ Considering the prevalence of benign prostatic hypertrophy there has been little investigation of its natural history. This information should be useful to evaluate the impact of medical and surgical treatment. What is the normal rate of progression of benign prostatic hypertrophy? How long must patients be followed before deterioration is detected? One retrospective study suggested that the progression of prostatism is highly variable.’ Can we predict which patients will need an operation or experience acute urinary retention? In this prospective study of the progression of benign prostatic hypertrophy, Zinsser systematically evaluated patients with prostatism at three to six-month intervals without therapy for

*This work has been supported in part by the Cournand Foundation, Inc., the Mollie and Harry Greenberg Gift for Research, and the Leo Model Gift for Medical Research, in the Columbia University Department of Urology. t Deceased.

18

periods up to ten years. This report is an analysis of his data. Material

and Methods

The patients evaluated were from a group of 156 who suffered from prostatism and seen initially between 1961 and 1970. Prostatic cancer developed in none. Of the group, 10 patients initially had absolute indications for prostatic surgery, namely, a residual urine persistently greater than I50 cc., azotemia, hydroureteronephrosis, or persistent urinary tract infection. Ninety-three patients were treated with various experimental drugs for the control of benign prostatic hypertrophy and are therefore excluded. Of the 53 patients who refused experimental drugs, 26 were followed for greater than three years and compose the study group (Group I). While being followed on no drug or on placebo, 9 patients experienced a total of ten episodes of acute retention (Group II). Thirteen additional patients underwent prostatectomies bringing the total treated with surgery to 23. At three to six-month intervals the symptomatic disability of each patient was scored (Table

UROLOGY

/

JANUARY 1976

/

VOLUME

VII,

NUMBER

1

TABLE I. Method

of subjective

scoring

Grade of Symptom Symptom

(Score)

Nocturia (times/night) Frequency (hours between voiding) Hesitancy Intermittency Dribbling Stream

ox 6

1 to 2x 4

4 6

3 to 4 4

None 6 Normal 4

Mild 4

Optimal Score 3x 0

6

2 to 3 2

2 0

6

Moderate 2 Diminished 0

Severe 0

2 to3x 2

6 6 6 4

TOTAL

34

I).An asymptomatic

patient would score 34 points and the most symptomatic 0 points. For clarity, results are expressed as per cent (+S.E.) with a score of 34 being 100 per cent. The objective scoring system was based on noninvasive techniques (Table II). The prostate was measured digitally after the patient voided. The maximum traverse and longitudinal measurements were expressed as an area. The maximum flow rate was recorded on either a Drake or an electronic flow meter (Scott Uroflowmeter). The residual urines were estimated by planimetry

TABLE II. Method

Prostatic Area (cm.“) Maximum flow rate (ml./sec.) Per cent PSP excreted in two hours

(ml.)

TOTAL

UROLOGY

of objective

scoring

Optimal Score

Measurement Score of Measurement

Parameter

Residual urine

from the postvoiding film of the excretory urogram.3 The per cent PSP (phenosulfonphthalein) was the total per cent excreted in four voidings, namely, at fifteen, thirty, sixty, and one hundred twenty minutes after intravenous injection of 6 mg. in 1 ml. (This measurement reflects both the renal function, and the residual urine.)4 Again, the best score (46) is expressed as 100 per cent. Statistical analysis was performed using the Student’s t and paired t tests with one tailed criterion for significance.

s4

>4s9

10

8

>9s12 6

>12sl6 4

>16s25 2

>25 0

>15 10

11-15 8

8-10 6

5-7 4

3-4 2

150 0

.

110-119 4

/ JANUARY1976

lo- 19 14 70-79 8

120- 129 3

/ VOLUME

130- 139

2

VII,NUMBER1

140- 149 1

0

10

10

10

11

16 46

49

so

SUBJECTIVE SCORE (PERCENT)

70 6o 60 40},

,

,

,

,

,

TIME

(YEARS)

,

,y

012345676

012345676 TIME (YEARS)

FIGURE 1. Observed progression of prostatism in 1 patient over jive years compared with predicted progress of study group.

SUBJECTIVE

PROSTATISM SCORE IN 26 PATIENTS

+50-

r

5

IMPROVED

F %

UNCHANGED

O-

k 5 Y

WORSENED

0

6mo.

I yaar

2 yaara

3ylJm

OBJECTIVE PROSTATISM SCORE IN 26

PATIENTS

+5c

In

5 Y

IMPROVE0

5

0

k t-

3

Results

GROUP MEAlv Ii S.DJ

r

UNCHANGED WORSENED

The progression of the symptoms and objective findings in 26 men with prostatism is shown in Table III. Both subjective and objective scores deteriorated during the three-year period (PcO.02 and P

Natural history of benign prostatic hypertrophy and acute urinary retention.

NATURAL HISTORY OF BENIGN PROSTATIC HYPERTROPHY AND ACUTE URINARY RETENTION* JOHN D. BIRKHOFF, A. ROGER M.D. WIEDERHORN, MARY L. HAMILTON, HAN...
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