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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

Alpha blockers are the first-line treatment for moderate to severe lower urinary tract symptoms (LUTS) due to BPH, with 5-alpha reductase inhibitors recommended for men with enlarged prostates (>30cc), and surgical intervention indicated for patients with complications or refractory symptoms. 1

Initial Medical Management

Alpha Blockers

• First-line treatment for moderate to severe LUTS due to BPH
• Mechanism: Relax smooth muscle in the prostate and bladder neck
• Options include:
  • Tamsulosin (Flomax)
  • Alfuzosin (Xatral)
  • Silodosin (Rapaflo)
• Benefits:
  • Quick onset of action (3-5 days)
  • Minimal side effects
  • Improve urinary symptoms 1, 2
• Common side effects:
  • Orthostatic hypotension
  • Dizziness
  • Tiredness
  • Nasal congestion 1
• Caution:
  • Inform ophthalmologist before cataract surgery (risk of intraoperative floppy iris syndrome)
  • Avoid in moderate/severe hepatic impairment
  • Avoid with potent CYP3A4 inhibitors 1

5-Alpha Reductase Inhibitors (5-ARIs)

• Recommended for men with enlarged prostates (>30cc)
• Options:
  • Finasteride (Proscar)
  • Dutasteride (Avodart)
• Benefits:
  • Reduce prostate size
  • Reduce risk of acute urinary retention by 67%
  • Reduce need for BPH-related surgery by 64%
  • May reverse disease progression 1, 3, 2
• Limitations:
  • Takes 6 months to assess effectiveness
  • Maximum prostate shrinkage at 12 months
  • Not effective for prostates <40ml 4
• Side effects:
  • Sexual dysfunction (decreased libido, ejaculation disorders)
  • Breast enlargement/tenderness 3

Combination Therapy

• Alpha blocker + 5-ARI combination is more effective than monotherapy for:
  • Patients with enlarged prostates (>30cc)
  • Moderate-to-severe symptoms
  • Preventing disease progression 1
• In the MTOPS study, combination therapy showed superior outcomes but increased side effects including:
  • Asthenia
  • Postural hypotension
  • Peripheral edema
  • Dizziness
  • Sexual dysfunction 3

Other Medical Options

• Phosphodiesterase-5 (PDE-5) inhibitors:
  • Tadalafil 5mg daily improves BPH symptoms
  • Particularly useful for patients with concomitant erectile dysfunction
  • Should not be combined with alpha blockers 1, 2

Watchful Waiting

• Appropriate for patients with mild symptoms who are not bothered by them 1
• No active intervention required, but regular monitoring recommended

Surgical and Minimally Invasive Treatments

• Indications for surgery:

  • Refractory urinary retention (after failed catheter removal attempt)
  • Renal insufficiency due to BPH
  • Recurrent UTIs due to BPH
  • Recurrent gross hematuria due to BPH
  • Bladder stones due to BPH 5

• Surgical options:

  • Transurethral Resection of the Prostate (TURP) - gold standard
  • Open prostatectomy (for very large prostates)
  • Transurethral incision of the prostate (for prostates <30g) 4, 6

• Minimally invasive options:

  • Laser procedures (HoLEP, Greenlight, thulium laser)
  • Prostatic urethral lift (PUL)
  • Transurethral microwave therapy
  • Transurethral needle ablation (TUNA)
  • Water-induced thermotherapy 5, 7

Treatment Algorithm

1. Assess symptom severity using validated questionnaires (IPSS/AUA Symptom Index)
2. For mild symptoms: Watchful waiting with lifestyle modifications
3. For moderate to severe symptoms:
   • First-line: Alpha blockers (tamsulosin, alfuzosin, silodosin)
   • For enlarged prostates (>30cc): Add 5-ARI (finasteride or dutasteride)
   • For concomitant ED: Consider tadalafil 5mg daily
4. For treatment failure or complications:
   • Surgical intervention (TURP or minimally invasive alternatives)

Monitoring and Follow-up

• Follow-up in 3-6 months after initiating therapy
• Monitor:
  • Symptom scores (IPSS/QoL)
  • Uroflowmetry/post-void residual
  • PSA levels (expect ~50% reduction after 12 months on 5-ARI) 1
• Regular monitoring of post-void residual volume to detect early signs of urinary retention

Important Caveats

• Phytotherapeutic agents (saw palmetto, pygeum, etc.) are not recommended for BPH treatment 5, 8
• Some minimally invasive therapies (interstitial laser coagulation, water-induced thermotherapy) require more data before being fully recommended 5
• High-intensity focused ultrasound and absolute ethanol injection are investigational and should only be used in clinical trials 5
• Balloon dilation is not an acceptable treatment option due to high failure rates 5