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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

The most effective treatment approach for BPH symptoms begins with alpha blockers as first-line therapy, with 5-alpha reductase inhibitors (5ARIs) added for patients with enlarged prostates (>30cc), and consideration of combination therapy for moderate to severe symptoms. 1, 2

Initial Evaluation and Assessment

• Use International Prostate Symptom Score (IPSS) to assess symptom severity
• Perform digital rectal examination to evaluate prostate size
• Conduct urinalysis to rule out infection or other conditions
• Consider post-void residual (PVR) measurement
• Determine prostate size (>30cc is significant for treatment decisions)

Treatment Algorithm

First-Line Approaches:

1. Watchful Waiting with Lifestyle Modifications

   • Appropriate for mild symptoms (IPSS <7) or non-bothersome moderate/severe symptoms 1, 2
   • Includes:
     • Limiting evening fluid intake
     • Reducing caffeine and alcohol consumption
     • Avoiding medications that worsen symptoms (decongestants, antihistamines)

2. Alpha Blockers

   • First-line pharmacological treatment for bothersome symptoms 1, 2
   • Options include:
     • Tamsulosin
     • Alfuzosin
     • Doxazosin
     • Silodosin
   • Rapid onset of action (3-5 days) 3
   • Common side effects: orthostatic hypotension, dizziness, ejaculatory problems 2, 4
   • Take with food and at bedtime to minimize side effects 4

3. 5-Alpha Reductase Inhibitors (5ARIs)

   • Particularly effective for enlarged prostates (>30cc) 1, 2
   • Options:
     • Finasteride: reduces risk of acute urinary retention by 67% 2, 5
     • Dutasteride: reduces serum DHT by ~95% 2, 6
   • Benefits:
     • Reduce prostate size by 20-30%
     • Decrease risk of disease progression
     • Reduce risk of acute urinary retention
     • Reduce need for BPH-related surgery 5, 6
   • Slower onset (3-6 months for full effect) 1, 2

Second-Line and Combination Approaches:

1. Combination Therapy

   • Alpha blocker + 5ARI for moderate-severe symptoms with enlarged prostate 1, 2
   • FDA-approved combinations:
     • Finasteride + tamsulosin
     • Dutasteride + tamsulosin 2
   • More effective than monotherapy but increases side effects 2

2. PDE5 Inhibitors

   • Tadalafil 5mg daily for BPH symptoms 2, 3
   • Particularly beneficial for patients with concurrent erectile dysfunction
   • Do not combine with alpha blockers due to risk of hypotension 2

3. Storage Symptom Management

   • For predominant storage symptoms (frequency, urgency, nocturia):
     • Beta-3-agonists (mirabegron) in combination with alpha blocker 2
     • Anticholinergics in combination with alpha blocker 2

Follow-Up and Monitoring

• Evaluate patients 4-12 weeks after starting alpha blockers 1, 2
• Evaluate patients 3-6 months after starting 5ARIs 1, 2
• Assessment should include:
  • IPSS score to evaluate symptom improvement
  • Evaluation of medication side effects
  • Consider PVR measurement
  • Consider uroflowmetry

Surgical Options

Consider surgical intervention if patient has:

• Failed medical therapy
• Recurrent urinary retention
• Recurrent UTIs
• Renal insufficiency
• Recurrent gross hematuria
• Bladder stones 2

Surgical options include:

• Transurethral Resection of the Prostate (TURP) - gold standard 2, 7
• Minimally invasive procedures:
  • Laser procedures (HoLEP, Greenlight, thulium laser)
  • Prostatic urethral lift (PUL) 2, 8

Common Pitfalls and Caveats

• Alpha blockers can cause orthostatic hypotension - advise patients to rise slowly from sitting/lying positions 2, 4
• 5ARIs can affect PSA levels - PSA values should be doubled for interpretation in patients on 5ARIs 2
• PDE5 inhibitors should not be combined with alpha blockers due to risk of significant hypotension 2
• Inform ophthalmologists about alpha blocker use before cataract surgery 4
• For post-void dribbling, recommend pelvic floor exercises and urethral milking technique 2

By following this evidence-based approach to BPH management, symptoms can be effectively controlled while minimizing side effects and improving quality of life for patients with this common condition.