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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

Treatment for BPH should be based on symptom severity, with watchful waiting recommended for mild or non-bothersome symptoms, alpha-blockers as first-line medical therapy for moderate to severe symptoms, and surgical interventions reserved for patients who fail medical management or have complications. 1

Assessment and Initial Management

• Treatment decisions should be guided by:
  • Symptom severity (using AUA Symptom Index/IPSS)
  • Degree of bother to the patient
  • Prostate size
  • Presence of complications

Watchful Waiting

• Indicated for:
  • Patients with mild symptoms (AUA Symptom Score <7)
  • Patients with moderate/severe symptoms who are not bothered by them 2, 1
• Approach includes:
  • Annual follow-up and symptom evaluation
  • Lifestyle modifications (fluid restriction before bedtime, limiting caffeine/alcohol)

Medical Therapy

Alpha-Blockers

• First-line medical treatment for moderate to severe bothersome symptoms
• Mechanism: Relax prostatic smooth muscle to improve urinary flow
• Options include:
  • Tamsulosin: Preferred due to specificity for alpha-1A receptors with fewer blood pressure effects 1, 3
  • Alfuzosin, doxazosin, terazosin: Alternative options
• Benefits:
  • Rapid onset (improvement within 4 weeks)
  • Improve symptoms by 4-6 points on AUA Symptom Index 1
• Side effects:
  • Orthostatic hypotension (especially with non-selective agents)
  • Dizziness, fatigue
  • Ejaculatory problems
  • Nasal congestion 1

5-Alpha Reductase Inhibitors

• Indicated for prostates larger than 30cc 1
• Options include:
  • Finasteride
  • Dutasteride
• Benefits:
  • Reduce prostate size over time
  • Decrease risk of acute urinary retention
  • Reduce need for surgery 1, 4
• Limitations:
  • Slower onset (6 months to assess effectiveness)
  • Not effective for prostates <40ml 3
  • Side effects include sexual dysfunction, decreased libido 4

Combination Therapy

• Alpha-blocker + 5-alpha reductase inhibitor
• Indicated for:
  • Large prostates with moderate to severe symptoms
  • Reducing risk of symptomatic progression 1, 4
• The MTOPS study showed combination therapy reduced risk of BPH progression more than either medication alone 4
• Side effects may be additive (higher rates of sexual dysfunction) 4

Surgical and Minimally Invasive Interventions

Indicated for:

• Patients who fail medical therapy
• Those with complications (recurrent UTIs, bladder stones, renal insufficiency)
• Patients preferring definitive treatment 1

Surgical Options

• Transurethral Resection of Prostate (TURP): Gold standard surgical treatment
• Transurethral Incision of Prostate (TUIP): For prostates <30g 3
• Laser procedures: HoLEP, Greenlight, Thulium laser 5
• Open prostatectomy: For very large prostates

Minimally Invasive Procedures

• Prostatic Urethral Lift (PUL)
• Transurethral microwave therapy
• Transurethral needle ablation
• Prostatic stents: Reserved for high-risk patients with urinary retention 1

Treatment Algorithm

1. Assess symptom severity and bother:

   • Use AUA Symptom Index/IPSS

2. For mild symptoms (AUA <7) or non-bothersome symptoms:

   • Watchful waiting with annual follow-up

3. For moderate to severe bothersome symptoms (AUA ≥8):

   • Small to moderate prostate (<30cc):

     • Start with alpha-blocker (tamsulosin preferred unless hypertensive)

   • Large prostate (>30cc):

     • Consider combination therapy (alpha-blocker + 5-alpha reductase inhibitor)
     • Or 5-alpha reductase inhibitor alone if concerned about alpha-blocker side effects

4. Evaluate response after 4-12 weeks:

   • If inadequate response or complications develop, consider surgical options

5. For acute urinary retention or other complications:

   • Consider immediate surgical intervention

Common Pitfalls and Caveats

• Underestimating symptom bother: The impact on quality of life should guide treatment decisions, not just symptom scores 2
• Inappropriate use of 5-alpha reductase inhibitors: Not effective for small prostates (<40ml) 3
• Failure to recognize complications: Untreated BPH increases risk of acute urinary retention, particularly in men over 70 1
• Overlooking medication side effects: Sexual dysfunction with 5-alpha reductase inhibitors; orthostatic hypotension with alpha-blockers
• Starting with full doses in elderly: Begin with lower doses of alpha-blockers in elderly patients to minimize orthostatic hypotension risk 1