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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

Alpha blockers should be used as first-line medical therapy for most patients with bothersome moderate to severe symptoms of BPH, with 5-alpha reductase inhibitors (5ARIs) added for patients with prostate volume >30cc. 1

Initial Evaluation and Assessment

The initial evaluation of patients with suspected BPH should include:

• Medical history
• Physical examination including digital rectal exam (DRE)
• International Prostate Symptom Score (IPSS) questionnaire
• Urinalysis 1

Based on symptom severity, patients can be categorized as:

• Mild symptoms (AUA Symptom Score <7)
• Moderate to severe symptoms (AUA Symptom Score ≥8) 1

Treatment Algorithm

Step 1: Watchful Waiting

• Appropriate for patients with mild symptoms or those with moderate/severe symptoms that don't interfere with daily activities
• Includes lifestyle modifications such as decreasing fluid intake at bedtime and reducing caffeine/alcohol consumption 1

Step 2: Medical Therapy

For patients with bothersome moderate to severe symptoms:

1. Alpha Blockers (First-line therapy)

   • Options: alfuzosin, doxazosin, tamsulosin, terazosin, silodosin
   • Mechanism: Relax smooth muscle in prostate and bladder neck
   • Benefits: Rapid symptom improvement (within days to weeks)
   • Side effects: Dizziness, orthostatic hypotension, retrograde ejaculation 1

2. 5-Alpha Reductase Inhibitors (5ARIs)

   • Options: finasteride, dutasteride
   • Mechanism: Reduce prostate size by inhibiting conversion of testosterone to dihydrotestosterone
   • Best for: Patients with prostate volume >30-40cc
   • Benefits: Reduce risk of acute urinary retention and need for surgery
   • Side effects: Sexual dysfunction, decreased libido, ejaculation disorders 1, 2
   • Note: Requires 6-12 months for maximum effect 3

3. Combination Therapy

   • Alpha blocker + 5ARI
   • Most effective for men with larger prostates (>30cc) and moderate-severe symptoms
   • Provides both immediate symptom relief and long-term disease progression benefits 1, 2

4. PDE5 Inhibitors

   • Emerging option, especially for patients with concurrent erectile dysfunction 4

Step 3: Surgical/Interventional Therapy

For patients who fail medical therapy or have complications:

1. Transurethral Resection of the Prostate (TURP)

   • Gold standard surgical treatment
   • Most effective for symptom relief
   • Higher risk of complications than medical therapy (bleeding, sexual dysfunction) 1

2. Minimally Invasive Surgical Therapies

   • Transurethral Microwave Thermotherapy (TUMT)
   • Transurethral Needle Ablation (TUNA)
   • Laser procedures (photoselective vaporization, holmium laser enucleation)
   • Benefits: Outpatient procedures, fewer complications, shorter recovery 1, 4

3. Prostatic Stents

   • Limited to high-risk patients with urinary retention who cannot undergo other procedures
   • Associated with complications like encrustation, infection, and chronic pain 1

Special Considerations

• Prostate Size: For prostates >30cc, consider 5ARIs alone or in combination with alpha blockers 1
• Erectile Dysfunction: Consider PDE5 inhibitors or careful selection of medical therapy 1
• Hypertension: Non-selective alpha blockers may provide dual benefit 3
• Acute Urinary Retention: Surgical intervention is typically recommended 1

Follow-up and Monitoring

Patients should be evaluated 4-12 weeks after initiating treatment to assess response and side effects. Evaluation should include IPSS, and may include post-void residual (PVR) and uroflowmetry 1.

Treatment Efficacy

• Alpha blockers: 15-20% improvement in symptoms and flow rates compared to placebo 3
• 5ARIs: Most effective in men with enlarged prostates (>40cc) 5
• Combination therapy: Superior to either monotherapy for long-term outcomes 5
• Surgical options: More effective than medical therapy but with higher complication rates 1

Remember that while BPH is rarely life-threatening, its impact on quality of life is significant and should not be underestimated when making treatment decisions 1.