Treatment of Benign Prostatic Hyperplasia (BPH)
The recommended first-line treatment for BPH depends on symptom severity: watchful waiting for mild symptoms (AUA score <7) and alpha blockers (such as tamsulosin) for moderate to severe symptoms (AUA score ≥8), with 5-alpha reductase inhibitors (finasteride or dutasteride) added for enlarged prostates (>30cc). 1
Assessment and Initial Management
Use the International Prostate Symptom Score (IPSS) or AUA Symptom Score to categorize severity:
- Mild symptoms (AUA score <7): Watchful waiting with annual follow-up
- Moderate to severe symptoms (AUA score ≥8): Medical therapy based on symptom bother
Lifestyle modifications for all patients:
- Limit evening fluid intake
- Reduce caffeine and alcohol consumption
- Avoid medications that worsen symptoms (decongestants, antihistamines)
Medical Therapy Options
Alpha Blockers (First-line for moderate-severe symptoms)
- Options: alfuzosin, doxazosin, tamsulosin (0.4mg daily), terazosin
- Benefits: Rapid symptom improvement (within days to weeks)
- Side effects: Dizziness, rhinitis, abnormal ejaculation 1, 2
- Tamsulosin is uroselective with minimal blood pressure effects, making it preferable in patients without hypertension 3, 2
5-Alpha Reductase Inhibitors (5-ARIs)
- Options: finasteride, dutasteride
- Indicated for enlarged prostates (>30cc)
- Benefits:
- Side effects: Sexual dysfunction, gynecomastia
- Takes 6-12 months for maximum effect 6
Combination Therapy
- Alpha blocker + 5-ARI combination is more effective than monotherapy for men with enlarged prostates and moderate-to-severe symptoms 1, 4, 5
- Finasteride + tamsulosin or dutasteride + tamsulosin combinations are FDA-approved 4, 5
Other Medical Options
- For predominant storage symptoms:
- Beta-3-agonists (mirabegron) in combination with alpha blockers
- Anticholinergics in combination with alpha blockers
- PDE-5 inhibitors (tadalafil 5mg daily) can improve BPH symptoms, particularly for patients with concomitant erectile dysfunction 1
Surgical Treatment
Surgery is recommended for patients with:
- Refractory urinary retention (failing at least one attempt at catheter removal)
- Recurrent UTIs due to BPH
- Renal insufficiency due to BPH
- Recurrent gross hematuria due to BPH
- Bladder stones due to BPH 7, 1
Surgical options include:
- Transurethral resection of the prostate (TURP) - gold standard
- Minimally invasive procedures (laser procedures, prostatic urethral lift)
- Open prostatectomy (for very large prostates)
Follow-up and Monitoring
- Evaluate patients 3-6 months after initiating therapy
- Assess:
- Symptom improvement using IPSS/AUA score
- Medication adherence and side effects
- Uroflowmetry and post-void residual volume
- PSA (doubled value if on 5-ARI)
Important Considerations and Pitfalls
- Alpha blockers can cause intraoperative floppy iris syndrome during cataract surgery; patients should inform their ophthalmologist before surgery
- 5-ARIs take 6-12 months for maximum effect; don't discontinue prematurely
- Patients on 5-ARIs should have PSA levels adjusted (doubled)
- Phytotherapeutic agents (saw palmetto, pygeum) are not recommended due to lack of evidence 1, 8
- Anticholinergic side effects should be monitored, especially in elderly patients
- Combination therapy increases efficacy but also increases side effects
By following this treatment algorithm, clinicians can effectively manage BPH symptoms while minimizing complications and improving patients' quality of life.