What is the most effective treatment for a 62-year-old male with benign prostatic hyperplasia (BPH) and overactive bladder symptoms?

From the Guidelines

The most efficacious treatment for this patient is transurethral resection of the prostate (TURP). This 62-year-old man presents with classic lower urinary tract symptoms (frequency, urgency, urge incontinence) with evidence of bladder outlet obstruction due to benign prostatic hyperplasia (BPH) 1. The high detrusor pressure (90 cm H2O) during voiding indicates that the bladder is working hard against obstruction, and the presence of bladder trabeculation on cystoscopy confirms chronic obstruction. While medical therapy with alpha-blockers (such as tamsulosin 0.4 mg daily) or 5-alpha reductase inhibitors (finasteride 5 mg daily) could be considered, the combination of high detrusor pressure, bladder trabeculation, and trilobar prostatic enlargement suggests that surgical intervention would provide more definitive relief 1.

Key Considerations

• The patient's symptoms and urodynamic findings are consistent with bladder outlet obstruction due to BPH 1.
• The presence of bladder trabeculation on cystoscopy confirms chronic obstruction 1.
• TURP would remove the obstructing prostatic tissue, reduce outlet resistance, and allow the bladder to empty more efficiently 1.
• Post-procedure, the patient should expect significant improvement in urinary flow and resolution of his storage symptoms, though he should be counseled about potential side effects including retrograde ejaculation 1.

Treatment Options

• Medical therapy with alpha-blockers or 5-alpha reductase inhibitors could be considered, but may not provide adequate relief for this patient 1.
• TURP is a more definitive treatment option that can provide significant improvement in symptoms and prevent further deterioration of bladder function 1.
• Other treatment options, such as minimally invasive therapies or open prostatectomy, may also be considered, but TURP is generally the most effective treatment for patients with similar symptoms and urodynamic findings 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.

1. 1 Monotherapy Finasteride tablets 5 mg/day was initially evaluated in patients with symptoms of BPH and enlarged prostates by digital rectal examination in two 1-year, placebo-controlled, randomized, double-blind studies and their 5-year open extensions Patients in A Long-Term Efficacy and Safety Study had moderate to severe symptoms at baseline (mean of approximately 15 points on a 0 to 34 point scale). Patients randomized to finasteride tablets who remained on therapy for 4 years had a mean (± 1 SD) decrease in symptom score of 3.3 (± 5. 8) points compared with 1.3 (± 5.6) points in the placebo group.

The most efficacious treatment for the patient's symptoms is finasteride 2, as it has been shown to improve symptoms, reduce the risk of acute urinary retention, and reduce the risk of the need for surgery in men with symptomatic BPH and an enlarged prostate.

• Key benefits of finasteride include:
  • Improvement in symptom score
  • Reduction in risk of acute urinary retention
  • Reduction in risk of BPH-related surgery
• Clinical evidence from A Long-Term Efficacy and Safety Study supports the use of finasteride in patients with moderate to severe BPH symptoms 2.

From the Research

Treatment Options for Benign Prostatic Hyperplasia (BPH)

The patient's symptoms of urinary frequency, urgency, and urge incontinence, along with a prostate size of 25 grams and trilobar enlargement, suggest a diagnosis of Benign Prostatic Hyperplasia (BPH).

Medical Management of BPH

• Alpha-blockers, such as tamsulosin, have been shown to be effective in improving symptoms and peak urine flow in patients with BPH 3, 4.
• 5-alpha-reductase inhibitors, such as finasteride, have been shown to reduce prostate volume and prevent disease progression in longer-term treatment 5, 6.
• Combination therapy with alpha-blockers and 5-alpha-reductase inhibitors has been shown to be beneficial in patients with an enlarged prostate, more severe symptoms, and higher PSA levels 5, 7.

Efficacy and Safety of Treatment Options

• Tamsulosin has been shown to be effective and well-tolerated in the treatment of LUTS associated with BPH, with a rapid onset of action and minimal effects on blood pressure 3, 4.
• Finasteride monotherapy has been shown to be effective in reducing prostate volume and improving symptoms, with a significant effect on IPSS score and Qmax 6.
• Combination therapy with alpha-blockers and 5-alpha-reductase inhibitors has been shown to be effective in reducing BPH-related symptoms and lowering the rate of overall clinical progression 5, 7.

Treatment Recommendations

Based on the patient's symptoms and prostate size, a combination of alpha-blocker and 5-alpha-reductase inhibitor therapy may be considered, as it has been shown to be beneficial in patients with an enlarged prostate and more severe symptoms 5, 7. However, the patient's individual needs and medical history should be taken into account when determining the most appropriate treatment plan.