What is the initial treatment for Benign Prostatic Hyperplasia (BPH)?

Initial Treatment for Benign Prostatic Hyperplasia (BPH)

Alpha blockers should be offered as first-line treatment for patients with bothersome, moderate to severe lower urinary tract symptoms (LUTS) due to BPH. 1

Treatment Algorithm for BPH

First-Line Treatment Options

Alpha Blockers

• Alpha blockers (alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin) provide rapid symptom relief within days to weeks
• All alpha blockers have similar clinical effectiveness with IPSS improvement of 4-7 points compared to 2-4 points with placebo 1
• Selection should be based on:
  • Patient age
  • Comorbidities (especially cardiovascular conditions)
  • Side effect profiles (ejaculatory dysfunction, blood pressure changes)
• Patients should be monitored for orthostatic hypotension, especially with non-uroselective agents

5-Alpha Reductase Inhibitors (5-ARIs)

• Appropriate for patients with demonstrable prostatic enlargement:
  • Prostate volume >30cc on imaging
  • PSA >1.5ng/mL
  • Palpable enlargement on digital rectal exam 1, 2
• Takes 6-12 months for maximum effect (20-30% reduction in prostate volume) 2
• Reduces risk of disease progression, acute urinary retention, and need for surgery 2
• Not appropriate for men without prostatic enlargement

Second-Line and Combination Therapy

Combination Therapy

• Alpha blocker + 5-ARI combination is recommended for patients with:
  • Moderate to severe symptoms AND
  • Demonstrable prostatic enlargement (>30cc) 1
• Alpha blocker + anticholinergic may be considered for patients with:
  • Moderate to severe predominant storage symptoms 1
• Alpha blocker + beta-3-agonist may be considered for patients with:
  • Moderate to severe predominant storage symptoms 1

PDE-5 Inhibitors

• Tadalafil is a reasonable option for selected patients, especially those with concomitant erectile dysfunction 1
• Should not be combined with alpha blockers as this offers no advantage over monotherapy 1

Monitoring and Follow-up

After initiating treatment:

• Assess symptom improvement using IPSS (International Prostate Symptom Score)
• Monitor for side effects
• For patients on 5-ARIs, adjust PSA values (approximately 50% reduction after 12 months) for prostate cancer screening purposes 2
• If inadequate response to initial therapy:
  • Consider combination therapy
  • Evaluate for other causes of LUTS
  • Consider urologic referral for additional workup

Important Considerations

• Watchful waiting is appropriate for patients with mild symptoms who are not bothered by them 1
• Alpha blockers provide faster symptom relief but do not alter disease progression
• 5-ARIs reduce prostate volume and disease progression but require longer treatment time for effect
• Combination therapy provides both immediate symptom relief and long-term disease modification but increases side effect risk
• Medical therapy has significantly reduced the need for surgical intervention for BPH by approximately 50% 3

Alpha blockers remain the cornerstone of initial BPH treatment due to their rapid onset of action and favorable side effect profile, while 5-ARIs should be reserved for men with enlarged prostates who would benefit from volume reduction and prevention of disease progression.