From the Guidelines
For benign prostatic hyperplasia (BPH), medical therapy is typically the first-line approach for mild to moderate symptoms, while surgery becomes appropriate when medical therapy fails, symptoms are severe, or complications occur. The choice between surgical and medical treatment depends on symptom severity, patient preference, and comorbidities 1. Medical therapy includes alpha-blockers like tamsulosin (0.4mg daily), alfuzosin (10mg daily), or silodosin (8mg daily) that provide rapid symptom relief by relaxing smooth muscle in the prostate and bladder neck. 5-alpha reductase inhibitors such as finasteride (5mg daily) or dutasteride (0.5mg daily) shrink the prostate over 3-6 months and work best for larger prostates (>40g) 1.
Some key points to consider in the management of BPH include:
- Combination therapy with both medication classes offers synergistic benefits for men with larger prostates and moderate-severe symptoms.
- PDE5 inhibitors like tadalafil (5mg daily) can also improve BPH symptoms, particularly in men with concurrent erectile dysfunction.
- Surgical options include transurethral resection of the prostate (TURP), laser procedures (HoLEP, GreenLight), UroLift, or Rezum water vapor therapy.
- TURP remains the gold standard surgical approach but newer, less invasive options offer quicker recovery with fewer side effects 1.
- The decision between medical and surgical management should be individualized based on prostate size, symptom severity, sexual function concerns, and patient preferences regarding potential side effects like retrograde ejaculation with surgery or sexual dysfunction with certain medications 1.
It's also important to note that patients who have developed complications of BPH are best treated surgically 1, and that surgery is an appropriate treatment option for patients with moderate-to-severe lower urinary tract symptoms (LUTS) and for patients who have developed acute urinary retention or other BPH-related complications 1. Additionally, patients who undergo radical prostatectomy (RP), and some patients who undergo radiation therapy (RT) or surgery for BPH, will experience incontinence, and may require further treatment 1.
From the Research
BPH Treatment Options
- Surgical treatment options for BPH include transurethral resection of the prostate (TURP) or open prostatectomy, which are currently the most effective therapies for BPH 2.
- 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 2.
- Medical therapy is becoming increasingly important in the treatment of patients with moderate symptoms of BPH, with options including alpha blockers, 5-alpha reductase inhibitors, and phosphodiesterase-5 inhibitors 3, 2, 4, 5.
Medical Treatment
- Alpha blockers, such as tamsulosin, alfusosin, and silodosin, can improve BPH-related symptoms and have minimal side effects 3.
- 5-alpha reductase inhibitors, such as finasteride and dutasteride, can decrease prostate volume, improve lower urinary tract symptoms, and reduce the risk of acute urinary retention and BPH-related surgery 2, 4, 5.
- Phosphodiesterase-5 inhibitors, such as tadalafil, can improve BPH-related symptoms and are currently approved to treat patients with BPH 3.
Treatment Considerations
- The choice of treatment for BPH should take into account the patient's preference, medical history, and the severity of their symptoms 2, 6.
- Patients with larger prostates may benefit from 5-alpha reductase inhibitors, while those with smaller prostates may respond better to alpha blockers 3, 2.
- Referral to a urologist can be considered for patients with a rising prostate-specific antigen (PSA), failure of urinary symptom control despite maximal medical therapy, suspicion of prostate cancer, hematuria, recurrent urinary infections, urinary retention, or renal failure 3.