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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

Treatment for BPH should follow a stepwise approach based on symptom severity, with watchful waiting for mild symptoms and medical therapy or surgical interventions for moderate to severe symptoms that impact quality of life.

Initial Assessment and Management Strategy

Symptom Classification

• Mild symptoms (AUA Symptom Score <7): Watchful waiting is recommended
• Moderate to severe symptoms (AUA Symptom Score ≥8):
  • If symptoms are not bothersome: Watchful waiting
  • If symptoms are bothersome: Consider active treatment options 1

Watchful Waiting

• Appropriate for patients with mild symptoms or non-bothersome moderate/severe symptoms
• Annual follow-up evaluations
• Simple measures that may help:
  • Decreasing fluid intake at bedtime
  • Reducing caffeine and alcohol consumption
  • Monitoring for symptom progression 1

Medical Therapy Options

Alpha-Adrenergic Blockers

• First-line medical therapy for most patients with moderate to severe symptoms
• Mechanism: Relax smooth muscle in prostate and bladder neck
• Options include:
  • Alfuzosin (once daily)
  • Doxazosin (once daily)
  • Tamsulosin (once daily) - more selective for alpha-1A receptors with minimal blood pressure effects
  • Terazosin (once daily) 1, 2
• Advantages:
  • Rapid onset of action (within weeks)
  • Improve symptoms by 15-20% compared to placebo
  • Not dependent on prostate size 2
• Side effects:
  • Dizziness, headache, asthenia
  • Ejaculatory dysfunction (more common with tamsulosin at 10% vs 0-1% with others) 3

5-Alpha-Reductase Inhibitors

• Finasteride - FDA approved for:
  • Treatment of symptomatic BPH in men with enlarged prostate
  • Reducing risk of acute urinary retention
  • Reducing need for surgery 4
• Best for patients with larger prostates (>40mL)
• Mechanism: Blocks conversion of testosterone to dihydrotestosterone, reducing prostate size
• Considerations:
  • Requires 6-12 months for maximum effect
  • Not effective for smaller prostates (<40mL) 2
• Side effects:
  • Sexual dysfunction (decreased libido, erectile dysfunction)
  • Decreased ejaculate volume
  • Breast tenderness/enlargement 4

Combination Therapy

• Alpha-blocker + 5-alpha-reductase inhibitor (e.g., doxazosin + finasteride)
• Indicated to reduce risk of symptomatic progression of BPH
• Higher incidence of adverse effects than monotherapy:
  • Sexual dysfunction (22.6% impotence with combination vs 14.4% with doxazosin and 18.5% with finasteride)
  • Ejaculatory dysfunction (14.1% with combination vs 4.5% with doxazosin and 7.2% with finasteride) 4

Surgical and Minimally Invasive Options

Surgical Therapies (for moderate-severe symptoms or complications)

• Transurethral Resection of the Prostate (TURP)

  • Gold standard surgical treatment
  • Most effective for symptom relief
  • Higher risk of complications (20% adverse events) 2
  • Sexual side effects: erectile dysfunction (10%), ejaculatory dysfunction (65%) 3

• Transurethral Incision of the Prostate (TUIP)

  • For prostates <30g
  • Fewer side effects than TURP 2

• Open Prostatectomy

  • For very large prostates
  • Most invasive option 1

Minimally Invasive Therapies

• Transurethral Microwave Thermotherapy (TUMT)

  • Outpatient procedure
  • Less effective than TURP but more effective than medical therapy
  • Lower risk of sexual dysfunction than surgery 1, 3

• Transurethral Needle Ablation (TUNA)

  • Effective for lateral lobe enlargement in prostates <60g
  • More effective than medical therapy but less effective than TURP
  • Common side effects: irritative symptoms, temporary retention 1

• Prostatic Stents

  • Should be considered only for high-risk patients with urinary retention
  • Associated with significant complications (encrustation, infection, chronic pain) 1

Treatment Algorithm for BPH

1. Assess symptom severity using AUA Symptom Score

2. For mild symptoms or non-bothersome moderate/severe symptoms:

   • Implement watchful waiting
   • Annual follow-up

3. For bothersome moderate to severe symptoms:

   • First-line: Alpha-blocker (tamsulosin if blood pressure concerns exist; doxazosin/terazosin if patient also has hypertension)

   • For large prostates (>40mL): Consider 5-alpha-reductase inhibitor (finasteride) or combination therapy

   • If medical therapy fails or is not tolerated: Consider surgical options

4. For complications of BPH (refractory retention, recurrent UTIs, bladder stones, renal insufficiency):

   • Surgery is recommended as first-line treatment 1
   • If patient is not a surgical candidate, consider catheterization or stent placement

Special Considerations

• Urinary retention: Surgery is recommended after failed catheter removal attempt. Alpha-blockers may be tried before catheter removal 1

• Sexual function: Discuss potential sexual side effects before initiating treatment:

  • Surgery: highest risk of ejaculatory dysfunction (65%)
  • 5-alpha-reductase inhibitors: moderate risk of erectile dysfunction and decreased libido
  • Alpha-blockers: variable risk (tamsulosin has highest risk of ejaculatory problems) 3

• Balloon dilation is not recommended as a treatment option for BPH 1

• High-intensity focused ultrasound and absolute ethanol injection are investigational and should not be offered outside clinical trials 1