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

From the Guidelines

Treatment options for Benign Prostatic Hyperplasia (BPH) should be individualized based on symptom severity, prostate size, and patient preferences, with a focus on minimizing morbidity, mortality, and improving quality of life.

Overview of Treatment Options

The following treatment options are available for BPH:

• Watchful waiting with annual monitoring for mild symptoms
• Medications, including alpha-blockers (tamsulosin 0.4mg daily, alfuzosin 10mg daily, or silodosin 8mg daily) and 5-alpha reductase inhibitors (finasteride 5mg daily or dutasteride 0.5mg daily)
• Minimally invasive procedures, such as transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), prostatic urethral lift (UroLift), or water vapor thermal therapy (Rezūm)
• Surgical options, including transurethral resection of the prostate (TURP), laser procedures (HoLEP, PVP), or open prostatectomy for extremely large glands

Selection of Treatment

Treatment selection should consider prostate size, symptom severity, sexual function concerns, comorbidities, and patient preferences 1.

Recent Guidelines

The most recent guidelines from 2021 recommend offering combination therapy with an alpha-blocker and a 5-alpha reductase inhibitor to patients with LUTS associated with demonstrable prostatic enlargement, as judged by a prostate volume of >30cc on imaging, a PSA >1.5ng/mL, or palpable prostate enlargement on DRE 1.

Considerations

It is essential to consider the potential risks and benefits of each treatment option, including the risk of de novo or worsening overactive bladder symptoms after BPH surgical interventions 1.

Recommendation

The most effective treatment approach for BPH should be based on the individual patient's needs and preferences, with a focus on minimizing morbidity, mortality, and improving quality of life, as recommended by the most recent guidelines from 2021 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.

1.2 Combination with Alpha-Blocker Finasteride tablets administered in combination with the alpha-blocker doxazosin is indicated to reduce the risk of symptomatic progression of BPH (a confirmed ≥ 4 point increase in American Urological Association (AUA) symptom score).

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 recommended treatment options for Benign Prostatic Hyperplasia (BPH) are:

• Finasteride (PO): to improve symptoms, reduce the risk of acute urinary retention, and reduce the risk of the need for surgery.
• Combination with Alpha-Blocker: finasteride administered in combination with the alpha-blocker doxazosin to reduce the risk of symptomatic progression of BPH.
• Tamsulosin (PO): 0.4 mg once daily to treat the signs and symptoms of BPH. 2 3

From the Research

Treatment Options for Benign Prostatic Hyperplasia (BPH)

• Lifestyle modification and smooth muscle relaxant alpha blocker therapy are initial management options for BPH 4
• Alpha blockers, such as tamsulosin, alfusosin, and silodosin, usually take effect quickly and have minimal side effects 4
• 5-alpha reductase inhibitors, such as finasteride and dutasteride, are effective for patients with larger prostates and can reduce the need for future BPH-related surgery 4, 5
• Phosphodiesterase-5 (PDE-5) inhibitors, such as tadalafil, may be considered for treating BPH, especially for patients with erectile dysfunction 4, 6

Medical Therapy for BPH

• Alpha blockers are considered first-line treatment for BPH, especially for men with small prostates 6
• 5-alpha reductase inhibitors are recommended for men with large symptomatic prostates 6
• Combination therapies can be used to provide short-term symptom relief with long-term disease management 6
• Overactive bladder (OAB) medications can be added or substituted for patients with persistent irritative storage symptoms after first-line BPH therapy 6

Surgical Options for BPH

• Surgery may be appropriate initial treatment in patients with severe symptoms who are not at high risk for complications 5
• Surgical referral is indicated if BPH-related complications develop, medical therapy fails, or the patient chooses it 7
• Transurethral resection of the prostate is effective in most patients, but it carries some risk of sexual dysfunction, incontinence, and bleeding 5, 8

Diagnosis and Assessment of BPH

• A history should include onset, duration, and severity of lower urinary tract symptoms and medication use to rule out other causes of symptoms 7
• Physical examination includes a digital rectal examination and assessment for bladder distention or neurologic impairment 7
• Recommended tests include serum prostate-specific antigen measurement and urinalysis to help identify infection, genitourinary cancer, or calculi as an alternative cause of lower urinary tract symptoms 7