Treatment Guidelines for Benign Prostatic Hyperplasia (BPH)
The treatment of BPH should follow a stepwise approach based on symptom severity, with watchful waiting for mild symptoms, medical therapy for moderate symptoms, and surgical intervention for severe symptoms or complications.
Initial Assessment
Use the AUA Symptom Index (identical to IPSS) to quantify symptom severity:
- Mild: Score 0-7
- Moderate: Score 8-19
- Severe: Score 20-35
Determine the level of "bother" or impact on quality of life
Perform digital rectal examination (DRE) to assess prostate size
Treatment Algorithm
1. Watchful Waiting
- Indicated for: Patients with mild symptoms (AUA score <7) or those with moderate/severe symptoms who are not bothered by them 1
- Approach:
- Annual follow-up with symptom assessment
- Lifestyle modifications:
- Decrease fluid intake at bedtime
- Reduce caffeine and alcohol consumption
2. Medical Therapy
- Indicated for: Patients with bothersome moderate to severe symptoms (AUA score ≥8) 1
Alpha-Adrenergic Blockers
- First-line option for rapid symptom relief
- Medications: Alfuzosin, doxazosin, tamsulosin, terazosin 1
- Dosing: For tamsulosin, 0.4 mg once daily, taken 30 minutes after the same meal each day; can increase to 0.8 mg if inadequate response after 2-4 weeks 2
- Benefits: Rapid onset of action, improves both voiding and storage symptoms
- Adverse effects: Orthostatic hypotension, dizziness, asthenia, ejaculatory problems, nasal congestion
5-Alpha-Reductase Inhibitors
- Best for: Patients with enlarged prostates (>40 mL) 3
- Medications: Finasteride, dutasteride
- Benefits:
- Improve symptoms
- Reduce risk of acute urinary retention
- Reduce need for surgery 4
- May prevent disease progression
- Limitations:
- Requires 6-12 months for maximum effect 3
- Less effective for smaller prostates (<40 mL)
- Sexual side effects
Combination Therapy
- Indicated for: Reducing risk of symptomatic progression of BPH 4
- Approach: Alpha-blocker plus 5-alpha-reductase inhibitor (e.g., doxazosin + finasteride)
- Benefits: More effective than monotherapy for preventing disease progression
3. Surgical Interventions
- Indicated for:
- Patients who failed medical therapy
- Those with severe symptoms preferring definitive treatment
- Absolute indications (require surgery): Renal insufficiency due to BPH, recurrent UTIs, recurrent gross hematuria, bladder stones due to BPH 1
Surgical Options:
- Transurethral Resection of Prostate (TURP): Gold standard surgical treatment 1
- Transurethral Incision of Prostate (TUIP): For prostates <30g 3
- Minimally Invasive Options:
- Transurethral microwave thermotherapy (TUMT)
- Transurethral needle ablation (TUNA)
- Laser procedures (vaporization, enucleation)
Special Considerations
Prostate size affects treatment choice:
- Small prostates (<30g): Alpha-blockers or TUIP
- Large prostates (>40g): 5-alpha-reductase inhibitors or combination therapy
Comorbidities:
- Hypertension: Consider nonselective alpha-blockers that can treat both conditions 3
- Sexual function concerns: Alpha-blockers may have fewer sexual side effects than 5-alpha-reductase inhibitors
Patient preference should be considered after discussing risks and benefits of each approach
Pitfalls to Avoid
- Delaying treatment for patients with absolute surgical indications (renal insufficiency, recurrent UTIs, bladder stones)
- Using 5-alpha-reductase inhibitors in small prostates (<40 mL) where they're less effective
- Expecting immediate results with 5-alpha-reductase inhibitors (takes 6-12 months for maximum effect)
- Overlooking the bother factor - treatment decisions should consider not just symptom severity but also how much symptoms bother the patient
- Failing to recognize complications requiring surgical intervention regardless of symptom severity
By following this evidence-based approach, clinicians can effectively manage BPH while minimizing morbidity and mortality and optimizing patients' quality of life.