What are the treatment options for Benign Prostatic Hyperplasia (BPH)?

From the Guidelines

Treatment of chronic prostatic hypertrophy, also known as benign prostatic hyperplasia (BPH), should typically start with watchful waiting for mild symptoms, and first-line medication therapy includes alpha-blockers such as tamsulosin (0.4 mg daily), alfuzosin (10 mg daily), or silodosin (8 mg daily) for moderate to severe symptoms. For larger prostates (>30cc), 5-alpha reductase inhibitors like finasteride (5 mg daily) or dutasteride (0.5 mg daily) can be added, which shrink the prostate by blocking testosterone conversion to dihydrotestosterone, though they take 3-6 months for full effect 1.

Stepwise Approach

The treatment approach for BPH is stepwise, based on symptom severity:

• Mild symptoms: Watchful waiting with lifestyle modifications, including limiting evening fluid intake, reducing alcohol and caffeine consumption, and avoiding medications that worsen symptoms like decongestants.
• Moderate to severe symptoms: First-line medication therapy includes alpha-blockers, which relax smooth muscle in the prostate and bladder neck to improve urine flow.
• Larger prostates (>30cc): 5-alpha reductase inhibitors can be added to alpha-blockers for symptom improvement and to prevent progression of LUTS/BPH.

Combination Therapy

Combination therapy with both alpha-blockers and 5-alpha reductase inhibitors is often more effective than either alone for moderate to severe BPH, especially in patients with prostatic enlargement as judged by a prostate volume of >30cc on imaging, a prostate specific antigen (PSA) > 1.5ng/mL, or palpable prostate enlargement on digital rectal exam (DRE) 1.

Additional Therapies

For patients with overactive bladder symptoms, anticholinergics or beta-3 agonists like mirabegron may be added to the treatment regimen. If medications fail or complications like recurrent urinary retention occur, surgical options include transurethral resection of the prostate (TURP), laser procedures, or newer minimally invasive techniques like prostatic urethral lift or water vapor thermal therapy. Treatment choice depends on prostate size, symptom severity, patient preference, and comorbidities.

Key Considerations

• Prostate size: Larger prostates (>30cc) may benefit from 5-alpha reductase inhibitors.
• Symptom severity: Moderate to severe symptoms require first-line medication therapy.
• Patient preference: Patients should be informed of the risks and benefits of each treatment option.
• Comorbidities: Treatment choice should take into account patient comorbidities.

Overall, the goal of treatment is to improve symptoms, prevent disease progression, and reduce the risk of complications, while minimizing side effects and improving quality of life 1.

From the FDA Drug Label

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.

Treatment of Chronic Prostatic Hypertrophy: Finasteride is indicated for the treatment of symptomatic Benign Prostatic Hyperplasia (BPH) in men with an enlarged prostate. The goals of treatment with finasteride include:

• Improving symptoms
• Reducing the risk of acute urinary retention
• Reducing the risk of the need for surgery, including transurethral resection of the prostate (TURP) and prostatectomy 2.

From the Research

Treatment Options for Chronic Prostatic Hypertrophy

• Transurethral resection of the prostate (TURP) or open prostatectomy are currently the most effective therapies for BPH, however, TURP is associated with clinically significant adverse events in 20% of patients 3
• Minimally invasive procedures, such as electrovaporisation, laser prostatectomy, transurethral needle ablation, high intensity focused ultrasound, transurethral microwave therapy and insertion of prostatic stents, can be performed instead of the standard surgical procedures 3
• Medical therapy is becoming increasingly important in the treatment of patients with moderate symptoms of BPH, with options including androgen-suppressing therapy and alpha-adrenoceptor blockade 3, 4

Medical Therapy

• Alpha-adrenoceptor antagonists, such as terazosin, doxazosin and tamsulosin, can be administered once daily and are effective in managing BPH-related lower urinary tract symptoms (LUTS) and improving the maximal urinary flow rate 3, 4, 5
• 5 alpha-reductase inhibitors, such as finasteride, can reduce prostate size and prevent disease progression in longer-term treatment, but may take 6-12 months to achieve maximum effectiveness 3, 4, 6, 7
• Combination therapy with alpha(1)ARAs and 5ARIs may be beneficial in patients with enlarged prostates, more severe symptoms, and higher PSA levels 6, 7

Combination Therapy

• The alpha-blocker + 5-ARI combination remains ideal for enlarged prostates, significantly reducing clinical progression risk compared to monotherapy 6, 7
• Alpha-blocker + PDE5 inhibitor combinations may be safe and potentially beneficial for men with concomitant erectile dysfunction 7
• Beta-3 agonists may show synergistic effects with alpha blockers for residual storage symptoms, offering similar efficacy to anticholinergics but with a better side effect profile 7