What are the treatments for Benign Prostatic Hyperplasia (BPH)?

Treatments for Benign Prostatic Hyperplasia (BPH)

The most effective treatment approach for BPH follows a structured algorithm based on symptom severity, with watchful waiting for mild symptoms, medical therapy (alpha-blockers and 5-alpha reductase inhibitors) for moderate symptoms, and surgical interventions for severe symptoms or complications. 1

Initial Assessment and Non-Pharmacological Management

• For mild symptoms (AUA Symptom Score <7), watchful waiting is the standard approach 1
• Lifestyle modifications can help manage symptoms:
  • Reduce overall fluid intake by 25% to decrease urinary frequency and urgency 1
  • Adopt a diet rich in fruits and vegetables and low in saturated fats 1
  • Moderate alcohol intake (up to 2 drinks per day) 1
  • Regular physical exercise 1
  • Weight loss for overweight or obese patients 1

Medical Therapy

First-Line Medications

• Alpha-blockers (e.g., alfuzosin, doxazosin, tamsulosin, terazosin):

  • Improve symptoms by 4-6 points on the AUA Symptom Index within 4 weeks 1
  • Work by relaxing smooth muscle in the prostate and bladder neck 2
  • Common side effects include dizziness, headache, and tiredness 2
  • Should be taken with food and with the same meal each day 2

• 5-alpha reductase inhibitors (5-ARIs):

  • Indicated for prostates larger than 30cc 1
  • Options include:
    • Finasteride: Improves symptoms, reduces risk of acute urinary retention, and reduces need for surgery 3
    • Dutasteride: Similar indications as finasteride 4
  • Take 3-6 months to achieve maximum effect
  • Side effects may include sexual dysfunction

Combination Therapy

• Alpha-blocker + 5-ARI combination:
  • Indicated to reduce risk of symptomatic progression of BPH 1
  • Particularly effective for large prostates with moderate to severe symptoms 1
  • Finasteride with doxazosin reduces risk of symptomatic progression 3
  • Dutasteride with tamsulosin is indicated for symptomatic BPH with enlarged prostate 4

Other Medical Options

• Phosphodiesterase-5 (PDE-5) inhibitors can play a role in treating BPH-LUTS 5
• Overactive bladder medications can be added if persistent irritative storage symptoms remain after first-line therapy 5

Surgical Interventions

Surgical treatment is appropriate for:

• Patients with moderate-to-severe LUTS who have failed medical therapy
• Patients with acute urinary retention or other BPH-related complications
• Patients who prefer surgery as initial treatment 6

Surgical Options

• Transurethral Resection of the Prostate (TURP):

  • Still considered the benchmark for surgical therapies 6, 1
  • Involves surgical removal of the prostate's inner portion via an endoscopic approach 6
  • Usually performed under general or spinal anesthesia, requires hospital stay 6
  • Complications include 1% risk of urinary incontinence and potential TURP syndrome (dilutional hyponatremia) 6

• Other Surgical Approaches:

  • Transurethral incision of the prostate (TUIP) 1
  • Laser procedures (HoLEP, Greenlight, thulium laser) 7
  • Prostatic urethral lift (PUL) 7
  • Minimally invasive procedures 1

• Prostatic Stents:

  • Associated with significant complications (encrustation, infection, chronic pain)
  • Should be considered only in high-risk patients, especially those with urinary retention 6

Treatment Algorithm

1. Assess symptom severity using validated tools (AUA Symptom Index or International Prostate Symptom Score)
2. For mild symptoms: Watchful waiting + lifestyle modifications
3. For moderate symptoms:
   • Small prostate: Alpha-blocker monotherapy
   • Large prostate (>30cc): 5-ARI or combination therapy
4. For severe symptoms or complications (recurrent UTIs, bladder stones, renal insufficiency):
   • Consider surgical intervention, with TURP as the gold standard
   • Selection of surgical approach depends on prostate size, surgeon's expertise, and patient comorbidities

Monitoring and Follow-up

• Evaluate patients 4-12 weeks after initiating treatment 1
• Assessment should include IPSS score, post-void residual (PVR), and uroflowmetry 1
• Maintain a bladder diary for 3 days to document fluid intake and voiding patterns 1

Common Pitfalls to Avoid

• Failing to rule out prostate cancer before treating for BPH
• Using dietary supplements like saw palmetto, which are not recommended for BPH management 8
• Delaying surgical intervention when complications are present
• Not monitoring for progression of BPH, which can increase risk of acute urinary retention, particularly in men over 70 1