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

Workup and Treatment for Benign Prostatic Hyperplasia (BPH)

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

Initial Diagnostic Workup

Required Components:

• Medical History

  • Assess severity and bother of lower urinary tract symptoms (LUTS)
  • Review medication use that could worsen symptoms
  • Evaluate family history of prostate disease
  • Assess fitness for potential surgical procedures
  • Consider voiding diaries for patients with nocturia 1

• Physical Examination

  • Digital rectal examination (DRE) to:
    • Exclude locally advanced prostate cancer
    • Estimate prostate size (though DRE tends to underestimate true size)
    • Assess prostate morphology 1, 2
  • Focused neurological examination to assess:
    • Mental status
    • Ambulatory status
    • Lower extremity neuromuscular function
    • Anal sphincter tone 1

• Symptom Assessment

  • International Prostate Symptom Score (IPSS) questionnaire 1, 3

• Urinalysis

  • Screen for hematuria and urinary tract infection
  • Rule out bladder cancer, UTI, urethral strictures, and bladder stones 1

Recommended Additional Tests:

• PSA Measurement should be offered to:

  • Patients with at least 10-year life expectancy where knowledge of prostate cancer would change management
  • Patients where PSA may guide BPH treatment decisions
  • PSA >1.5ng/mL combined with prostate volume >30cc predicts better response to 5-ARIs 1, 2

• Post-void Residual (PVR) and Uroflowmetry

  • Recommended at follow-up visits to assess treatment response 1
  • Helps identify bladder outlet obstruction 4

Optional Tests (Based on Clinical Presentation):

• Prostate Volume Assessment via transrectal or transabdominal ultrasound

  • Particularly important when considering 5-ARI therapy (prostate must be >30cc)
  • Helpful when planning surgical interventions 2

• Urine Cytology

  • Consider for patients with predominantly irritative symptoms 1

Treatment Algorithm

Step 1: Assess Symptom Severity

• Mild or Non-bothersome Symptoms
  • Watchful waiting with lifestyle modifications 1, 5
  • Fluid management
  • Avoidance of bladder irritants
  • Timed voiding

Step 2: Medical Therapy for Bothersome Symptoms

• First-line: Alpha Blockers

  • Options: alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin 1
  • Tamsulosin dosing: 0.4mg once daily, approximately 30 minutes after the same meal each day 6
  • Rapid onset of action (3-5 days) 7
  • Follow-up in 4 weeks to assess response 1

• For Prostate Volume >30cc or PSA >1.5ng/mL

  • Consider adding 5-alpha reductase inhibitor (5-ARI)
    • Options: finasteride or dutasteride 1, 8
    • Finasteride reduces risk of acute urinary retention and need for surgery 8
    • Follow-up in 3-6 months due to slower onset of action 1

• For Patients with Erectile Dysfunction and BPH

  • Consider PDE5 inhibitors (e.g., tadalafil 5mg daily) 1, 7

• For Persistent Storage Symptoms Despite Alpha Blocker

  • Consider adding anticholinergics or beta-3 agonists 1

Step 3: Surgical Referral

• Indications for Urologic Referral
  • Failure to respond to medical therapy
  • Intolerable medication side effects
  • Complications of BPH:
    • Urinary retention
    • Recurrent UTIs
    • Bladder stones
    • Renal insufficiency
    • Hematuria 1, 7, 5

Follow-up Evaluation

• Timing

  • For alpha blockers, anticholinergics, beta-3 agonists, PDE5s: 4 weeks
  • For 5-ARIs: 3-6 months 1

• Assessment at Follow-up

  • IPSS score
  • Medication side effects
  • Consider PVR and uroflowmetry 1

Important Considerations and Pitfalls

• Alpha Blockers and Cataract Surgery

  • Inquire about planned cataract surgery before starting alpha blockers
  • Inform patients about risk of Intraoperative Floppy Iris Syndrome (IFIS) 1

• 5-ARI Side Effects

  • Inform patients about potential sexual side effects before starting therapy 1
  • Monitor PSA in patients on 5-ARIs (expect ~50% reduction after 6 months)

• Combination Therapy Considerations

  • Alpha blocker + 5-ARI combination has more side effects than monotherapy
  • Most common side effects: asthenia, postural hypotension, dizziness, decreased libido, and ejaculatory dysfunction 8

• Supplements

  • Saw palmetto, pygeum, and beta sitosterols are not recommended for BPH management 3

By following this structured approach to BPH evaluation and management, clinicians can effectively address patient symptoms while minimizing complications and improving quality of life.