What is the recommended workup and treatment for Benign Prostatic Hyperplasia (BPH)?

Workup and Treatment for Benign Prostatic Hyperplasia (BPH)

The initial evaluation for BPH should include a medical history, physical examination with digital rectal exam, International Prostate Symptom Score (IPSS), and urinalysis, followed by medical therapy with an alpha blocker as first-line treatment for most patients. 1

Initial Diagnostic Evaluation

Required Components:

• Medical history: Focus on LUTS symptoms, duration, severity, and medication use that could affect urinary function
• Physical examination:
  • Digital rectal examination (DRE) to assess prostate size and exclude cancer
  • Focused neurological examination to assess mental status, ambulatory status, lower extremity function, and anal sphincter tone 1
• International Prostate Symptom Score (IPSS): Standardized questionnaire to quantify symptom severity
• Urinalysis: To screen for hematuria and urinary tract infection 1

Recommended Components:

• PSA measurement: Should be offered to patients with:
  • At least 10-year life expectancy where knowledge of prostate cancer would change management
  • Cases where PSA measurement may influence management of voiding symptoms 1
  • PSA >1.5 ng/mL may indicate enlarged prostate suitable for 5-ARI therapy 1

Optional Components (based on clinical presentation):

• Post-void residual (PVR): To assess bladder emptying
• Uroflowmetry: To quantify urinary flow rate
• Prostate volume assessment: Via transrectal or transabdominal ultrasound when considering medical therapy with 5-ARIs (prostate >30cc) or surgical interventions 2

Treatment Algorithm

Step 1: Initial Approach

• Mild symptoms (minimal bother): Behavioral and lifestyle modifications
  • Fluid restriction in evening
  • Limiting caffeine and alcohol
  • Timed voiding

Step 2: Medical Therapy for Moderate to Severe Symptoms

• First-line: Alpha blockers 1

  • Options: alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin
  • Tamsulosin starting dose: 0.4 mg once daily, approximately 30 minutes after the same meal each day 3
  • Expect symptom improvement within 3-5 days 4
  • Follow-up in 4-12 weeks to assess response using IPSS 1

• For enlarged prostates (>30cc by imaging, PSA >1.5ng/mL, or palpable enlargement on DRE): 1, 2

  • Add 5-alpha reductase inhibitor (5-ARI) such as finasteride
  • Finasteride is indicated to:
    • Improve symptoms
    • Reduce risk of acute urinary retention
    • Reduce need for surgery 5
  • 5-ARIs take 3-6 months for full effect 1

Step 3: Follow-up and Treatment Adjustment

• Evaluate patients 4-12 weeks after initiating treatment 1
• If alpha blocker therapy fails or causes intolerable side effects:
  • Consider changing medication or adding another agent
  • Consider urologic referral for additional workup (urodynamics, cystoscopy, prostate volume assessment)

Step 4: Surgical Options

• Consider surgical referral if:
  • Medical therapy fails
  • Patient develops complications (urinary retention, recurrent UTIs, bladder stones, renal insufficiency)
  • Patient prefers surgical intervention 1

Important Considerations

Medication Selection

• Alpha blockers: Select based on patient age, comorbidities, and side effect profiles
  • Tamsulosin and silodosin have fewer blood pressure effects but more ejaculatory dysfunction
  • Doxazosin and terazosin may benefit patients with hypertension but require dose titration 1, 6

Special Precautions

• Inform patients on alpha blockers about intraoperative floppy iris syndrome risk if cataract surgery is planned 1
• Before starting 5-ARIs, inform patients about potential sexual side effects 1

Treatment Efficacy Monitoring

• Use IPSS and Global Subjective Assessment to evaluate treatment response
• If no improvement or worsening symptoms occur, reassess diagnosis and consider alternative treatments 1

Common Pitfalls to Avoid

• Failing to rule out other causes of LUTS (urinary tract infection, prostate cancer, neurogenic bladder)
• Using 5-ARIs in patients with small prostates (<30cc) where they are ineffective 2, 6
• Not considering prostate morphology (including middle lobe presence) when selecting treatment 2
• Relying solely on PSA without considering prostate size for treatment decisions 2
• Delaying surgical referral when medical therapy fails or complications develop

By following this structured approach to BPH diagnosis and management, clinicians can effectively address symptoms, improve quality of life, and reduce the risk of complications associated with this common condition.