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

Best Treatment Approach for Benign Prostatic Hyperplasia (BPH)

Alpha blockers should be used as first-line treatment for moderate to severe LUTS due to BPH, with 5-alpha reductase inhibitors added for men with enlarged prostates (>30cc), and surgical intervention reserved for patients with complications or who fail medical therapy. 1

Initial Assessment and Treatment Selection

Symptom Severity Assessment

• Use the International Prostate Symptom Score (IPSS) or American Urological Association (AUA) Symptom Score to categorize severity:
  • Mild symptoms (AUA score <7): Watchful waiting
  • Moderate to severe symptoms (AUA score ≥8): Treatment options depend on symptom bother

Treatment Algorithm Based on Symptom Severity

For Mild or Non-bothersome Symptoms:

• Watchful waiting is the standard approach for patients with mild symptoms (AUA score <7) or those with moderate/severe symptoms that don't bother them 2
• Annual follow-up with symptom assessment
• Lifestyle modifications:
  • Limit evening fluid intake
  • Reduce caffeine and alcohol consumption
  • Avoid medications that can worsen symptoms (decongestants, antihistamines)
  • Rise slowly from sitting or lying positions 1

For Moderate to Severe Bothersome Symptoms:

1. First-line: Alpha blockers

   • Options include alfuzosin, doxazosin, tamsulosin, and terazosin 2, 1
   • Quick onset of action (3-5 days) 3
   • Benefits: Rapid symptom improvement with minimal side effects
   • Side effects: Orthostatic hypotension, dizziness, asthenia
   • Caution: Inform ophthalmologists before cataract surgery due to risk of intraoperative floppy iris syndrome 1

2. For Enlarged Prostates (>30cc):

   • 5-alpha reductase inhibitors (5-ARIs): finasteride or dutasteride
   • Benefits: Reduce prostate size, risk of acute urinary retention by 67%, and need for BPH-related surgery by 64% 1, 4
   • Takes 6-12 months for maximum effect 5
   • Side effects: Sexual dysfunction (decreased libido, erectile dysfunction), gynecomastia 1, 4
   • PSA monitoring: Double PSA values for men on 5-ARIs 1

3. Combination Therapy:

   • Alpha blocker + 5-ARI for men with enlarged prostates and moderate-to-severe symptoms 1
   • More effective than monotherapy but increases side effects 1
   • Finasteride + doxazosin combination reduces risk of symptomatic progression of BPH 4

4. Additional Medical Options:

   • PDE-5 inhibitors (tadalafil 5mg daily) for patients with concomitant erectile dysfunction 1, 3
   • Beta-3-agonists (mirabegron) or anticholinergics for predominant storage symptoms, often in combination with alpha blockers 1

Surgical Interventions

Surgical treatment is indicated for patients with:

• Refractory urinary retention
• Recurrent urinary tract infections
• Renal insufficiency due to BPH
• Recurrent gross hematuria
• Bladder stones 1

Surgical Options:

1. Transurethral Resection of the Prostate (TURP): Gold standard surgical treatment 1, 6
2. Minimally Invasive Procedures:
   • Laser procedures (HoLEP, Greenlight, thulium laser)
   • Prostatic urethral lift (PUL) 1, 6
3. Open prostatectomy: For very large prostates 1

Monitoring and Follow-up

• Follow-up at 3-6 months after initiating therapy 1
• Assess:
  • Symptom improvement using IPSS/AUA score
  • Medication adherence and side effects
  • Uroflowmetry and post-void residual volume
  • PSA (remember to double the value if on 5-ARI) 1

Common Pitfalls to Avoid

1. Delayed treatment of complications: Monitor for urinary retention, renal insufficiency, and recurrent infections
2. Ignoring prostate size: Treatment effectiveness varies based on prostate volume
3. Overlooking drug interactions: Alpha blockers can cause hypotension when combined with other antihypertensives
4. Inadequate follow-up: Regular monitoring is essential to assess treatment response
5. Phytotherapy: Plant extracts like saw palmetto are not recommended due to lack of evidence 1

Remember that men with large post-void residual volumes (>350 ml) may have bladder dysfunction and might have a less favorable response to treatment 2. However, residual urine alone is not a contraindication to medical therapy or watchful waiting.