Treatment Options for Benign Prostatic Hyperplasia (BPH)
Behavioral modifications should be offered as first-line therapy to all patients with BPH before initiating medical therapy, followed by alpha-blockers as the primary medical treatment for symptomatic BPH, with 5-alpha reductase inhibitors added for patients with enlarged prostates. 1
First-Line Treatment: Behavioral Modifications
- Reduce overall fluid intake by 25% to decrease urinary frequency and urgency
- Adopt a diet rich in fruits and vegetables and low in saturated fats
- Moderate alcohol intake (up to 2 drinks per day)
- Regular physical exercise
- Weight loss for overweight or obese patients
- Use the International Prostate Symptom Score (IPSS) to assess baseline symptoms and monitor response
- Maintain a bladder diary for 3 days to document fluid intake and voiding patterns
Medical Therapy Options
Alpha-Blockers
- First-line medical treatment for moderate to severe symptoms (IPSS ≥8)
- Options include alfuzosin, doxazosin, tamsulosin, and terazosin
- Improve symptoms by 4-6 points on the AUA Symptom Index within 4 weeks
- Tamsulosin is preferred due to specificity for alpha-1A receptors with fewer blood pressure effects 1
5-Alpha Reductase Inhibitors
- Indicated for prostates larger than 30cc
- Options include finasteride and dutasteride
- Benefits include:
- Finasteride specifically is FDA-approved to:
- Improve symptoms
- Reduce the risk of acute urinary retention
- Reduce the risk of surgery including TURP and prostatectomy 2
Combination Therapy
- Alpha-blocker + 5-alpha reductase inhibitor
- Indicated to reduce the risk of symptomatic progression of BPH
- Particularly effective in large prostates with moderate to severe symptoms
- Finasteride with doxazosin is specifically indicated to reduce the risk of symptomatic progression of BPH 1, 2
Surgical and Minimally Invasive Options
- Reserved for patients who fail medical therapy or have complications such as:
- Recurrent UTIs
- Bladder stones
- Renal insufficiency 1
Surgical Options
- Transurethral resection of the prostate (TURP) - still considered the benchmark therapy
- Transurethral incision of the prostate (TUIP)
- Laser procedures 3, 1
Minimally Invasive Options
- Transurethral microwave thermotherapy (TUMT)
- Transurethral needle ablation (TUNA)
- Prostatic stents (reserved for high-risk patients with urinary retention) 3, 1
Treatment Selection Algorithm
- Mild symptoms: Watchful waiting with behavioral modifications
- Moderate to severe symptoms:
- Start with behavioral modifications
- If inadequate response after 4-12 weeks, add alpha-blocker
- For prostate size >30cc, consider adding 5-alpha reductase inhibitor
- For large prostates with moderate-severe symptoms, consider combination therapy
- Failed medical therapy or complications: Consider surgical intervention
Important Considerations and Monitoring
- Evaluate patients 4-12 weeks after initiating treatment
- Assessment should include IPSS score, post-void residual (PVR), and uroflowmetry
- Monitor for adverse effects:
- Untreated BPH can increase the risk of acute urinary retention, particularly in men over 70 years old 1
Caveats and Pitfalls
- Alpha-blockers provide rapid symptom relief but do not prevent disease progression
- 5-alpha reductase inhibitors take longer to work (3-6 months) but address the underlying pathophysiology
- Combination therapy has higher rates of adverse effects than either medication alone
- Finasteride is not approved for the prevention of prostate cancer 2
- Prostate size should be assessed before choosing therapy, as treatment efficacy varies based on prostate volume 3, 1
Medical therapy has significantly reduced the need for surgical intervention in BPH, with alpha-blockers being the most commonly used first-line medical treatment 4.