What is the most effective treatment for a 62-year-old man with urinary frequency, urgency, and urge incontinence due to benign prostatic hyperplasia (BPH) with a 25-gram prostate and overactive bladder symptoms?

Treatment for a 62-Year-Old Man with BPH and Overactive Bladder Symptoms

The most efficacious treatment for this patient is TURP (Transurethral Resection of the Prostate).

Patient Assessment and Diagnosis

This 62-year-old man presents with:

• Urinary frequency, urgency, and urge incontinence (storage symptoms)
• Normal urinalysis and culture (ruling out infection)
• 25-gram prostate with benign feel on DRE
• High detrusor pressure (90 cm H2O) with adequate voided volume (210 mL)
• Trilobar prostatic enlargement on cystourethroscopy
• Trabeculated bladder (indicating chronic obstruction)

These findings indicate both benign prostatic obstruction (BPO) and detrusor overactivity, with evidence of bladder outlet obstruction causing secondary overactive bladder symptoms.

Treatment Decision Algorithm

1. Identify primary pathology:

   • High detrusor pressure (90 cm H2O) indicates significant bladder outlet obstruction
   • Trabeculated bladder confirms chronic obstruction
   • Storage symptoms likely secondary to obstruction

2. Treatment options analysis:

   • TURP (Option A):

     • Addresses the primary cause (obstruction)
     • Shown to improve both voiding and storage symptoms in men with BPH and OAB 1
     • Directly relieves the high detrusor pressure and trabeculation

   • Oxybutynin alone (Option B):

     • May worsen retention in setting of obstruction
     • Contraindicated as monotherapy with high detrusor pressure 1
     • Treats symptoms but not underlying cause

   • Prazosin (Option C):

     • Alpha-blocker monotherapy insufficient for established trabeculation
     • Less effective than TURP for severe obstruction 1

   • Finasteride plus oxybutynin (Option D):

     • 5-ARIs work slowly and are most effective for larger prostates (>40g)
     • Risk of urinary retention with anticholinergic in obstructed patient 1

   • Finasteride plus terazosin (Option E):

     • Combination therapy effective for BPH 1
     • But insufficient for established trabeculation and high detrusor pressure
     • Better for progressive management before severe changes occur

Evidence Supporting TURP

The patient demonstrates clear signs of established bladder outlet obstruction:

• High detrusor pressure (90 cm H2O)
• Trabeculated bladder on cystourethroscopy
• Storage symptoms despite modest prostate size

According to AUA guidelines, "Men with OAB predominant LUTS and BPH have showed significant improvements in Qmax, PVR, and the presence of detrusor overactivity after transurethral resection of the prostate... Patients also had significant improvement on International Prostate Symptom Scores, frequency, urgency, nocturia, and urinary incontinence" 1.

The 2013 guidelines on LUTS in older men state that "If interventional therapy is chosen the patient should be referred to the specialist" and "TURP is still the gold standard for interventional treatment" 1.

Why Medication Options Are Less Effective

• Alpha blockers alone (prazosin/terazosin): While effective for mild to moderate BPH, they are insufficient when bladder trabeculation has already developed 1.

• Anticholinergics alone (oxybutynin): Contraindicated as monotherapy in men with significant obstruction due to risk of urinary retention 1, 2.

• Combination medical therapy: While the AUA guidelines note that "combination therapy with an alpha blocker and an antimuscarinic medication or beta-3 agonist" can be effective 1, this is more appropriate for patients without established trabeculation and high detrusor pressures.

Important Caveats

• Post-TURP, some patients may experience temporary worsening of storage symptoms that typically resolve within 3 months
• Monitoring for bleeding is necessary after TURP
• Medical therapy could be considered if the patient refuses surgery or has prohibitive surgical risk
• If medical therapy is chosen despite obstruction, close monitoring for urinary retention is essential, particularly in the first 30 days 2

In this case, with established obstruction evidenced by trabeculation and high detrusor pressure, TURP offers the most definitive solution to address both the obstruction and the secondary overactive bladder symptoms.