What is the approach to managing obstructive prostate symptoms, specifically Benign Prostatic Hyperplasia (BPH)?

From the Guidelines

The approach to obstructive prostate symptoms, also known as benign prostatic hyperplasia (BPH), begins with lifestyle modifications and first-line medication therapy, typically involving alpha-blockers, with surgical options considered if medications fail or complications develop, as recommended by the most recent guidelines 1.

Initial Management

The initial management of BPH involves lifestyle modifications, including:

• Limiting evening fluid intake
• Reducing alcohol and caffeine consumption
• Avoiding medications that worsen symptoms, such as decongestants

Medical Therapy

First-line medication therapy typically involves:

• Alpha-blockers, such as tamsulosin (0.4mg daily), alfuzosin (10mg daily), or silodosin (8mg daily), which relax smooth muscle in the prostate and bladder neck to improve urine flow within days
• For larger prostates (>40g), 5-alpha reductase inhibitors like finasteride (5mg daily) or dutasteride (0.5mg daily) can be added to reduce prostate size over 3-6 months
• Combination therapy with both medication classes is often more effective than either alone for moderate to severe symptoms

Surgical Options

If medications fail or complications develop (recurrent UTIs, bladder stones, renal insufficiency), surgical options include:

• Transurethral resection of the prostate (TURP)
• Laser procedures
• Minimally invasive techniques like UroLift These treatments work by reducing prostate tissue or creating a channel through the prostate to improve urine flow.

Considerations

Regular follow-up is essential to monitor symptom improvement and medication side effects, and clinicians should discuss the potential benefits and harms of each treatment option with patients, including the risk of de novo or worsening overactive bladder symptoms after BPH surgical interventions 1.

From the FDA Drug Label

1.1 Monotherapy Finasteride tablets are indicated for the treatment of symptomatic benign prostatic hyperplasia (BPH) in men with an enlarged prostate to:

• Improve symptoms
• Reduce the risk of acute urinary retention
• Reduce the risk of the need for surgery including transurethral resection of the prostate (TURP) and prostatectomy.

2 DOSAGE & ADMINISTRATION Tamsulosin Hydrochloride Capsules 0.4 mg once daily is recommended as the dose for the treatment of the signs and symptoms of BPH.

The approach to obstructive prostate symptoms includes the use of medications such as finasteride 2 and tamsulosin 3.

• Finasteride is indicated to improve symptoms and reduce the risk of complications associated with BPH.
• Tamsulosin is recommended for the treatment of the signs and symptoms of BPH at a dose of 0.4 mg once daily. Key considerations for the treatment of obstructive prostate symptoms include the use of these medications as part of a comprehensive management plan.

From the Research

Approach to Obstructive Prostate Symptoms

The approach to obstructive prostate symptoms involves a combination of watchful waiting, medication, and surgery.

• The Simplified Treatment for Enlarged Prostate (STEP) plan is a logical guide to patient management by the primary care provider (PCP) 4.
• This plan involves:
  • Watchful waiting for patients with symptoms that are not bothersome
  • Initiation of an alpha-blocker for patients with bothersome symptoms
  • Combination treatment with an alpha-blocker and a 5alpha-reductase inhibitor for patients with bothersome symptoms and a PSA > or = 1.5 ng/ml
  • Referral to a urologist for patients with refractory symptoms

Medical Treatment Options

Medical treatment options for benign prostatic hyperplasia (BPH) include:

• 5 alpha-reductase inhibitors, which inhibit the conversion of testosterone to dihydrotestosterone and decrease the size of the prostate 5
• Alpha-adrenergic antagonists, which decrease the smooth muscle tone of the bladder neck, prostatic adenoma, and prostatic capsule 5
• Combination therapy with dutasteride and tamsulosin, which has been shown to be effective in improving symptoms and reducing the risk of acute urinary retention and surgery 6

Treatment of Acute Urinary Retention

The treatment of acute urinary retention due to BPH may involve:

• Single or double dose alpha-blocker therapy, with double dose therapy showing superior efficacy and safety in some studies 7
• Catheterization and trial without catheter (TWOC) to assess the patient's ability to void spontaneously

Factors Influencing Treatment

Factors that may influence treatment decisions include:

• Prostate-specific antigen (PSA) level, with higher levels indicating a greater risk of disease progression 4, 6
• Prostate volume, with larger prostates indicating a greater risk of disease progression 6
• Symptom severity and bother, with more severe symptoms requiring more aggressive treatment 4