Diagnosis and Treatment of Benign Prostatic Hyperplasia (BPH)
The recommended approach for BPH management begins with quantifying symptom severity using the International Prostate Symptom Score (IPSS), followed by a structured diagnostic evaluation and treatment selection based on symptom severity, with alpha blockers as first-line therapy for moderate symptoms and combination therapy or surgical options for severe symptoms. 1
Initial Diagnostic Evaluation
Required Tests:
- International Prostate Symptom Score (IPSS): Classifies symptoms as mild (0-7), moderate (8-19), or severe (20-35) 1
- Quality of Life (QoL) score: Critical for determining treatment necessity 1
- Digital Rectal Examination (DRE): Mandatory to assess prostate size and characteristics 1, 2
- Urinalysis: To rule out infection or hematuria 1
Recommended Tests:
- Serum PSA: For patients with >10-year life expectancy or when it might change management 1
- Serum creatinine: To assess renal function 2
- Uroflowmetry: Recommended before invasive therapy 1
- Post-void residual urine measurement: To assess bladder emptying 1, 2
Optional Tests (primarily for patients considering invasive therapy):
- Pressure-flow urodynamic studies: Only for patients considering surgery with Qmax >10 ml/sec 3
- Urethrocystoscopy: Only for patients with hematuria, stricture risk factors, suspected bladder cancer, or prior lower urinary tract surgery 3
- Prostate ultrasound: When considering minimally invasive or surgical interventions 3
- Frequency-volume chart: Particularly useful when nocturia is the dominant symptom 1
Treatment Algorithm
Mild Symptoms (IPSS 0-7):
- Watchful waiting with annual follow-up 1
- Lifestyle modifications:
- Decrease fluid intake at bedtime
- Reduce caffeine/alcohol consumption 1
Moderate Symptoms (IPSS 8-19):
- First-line: Alpha blockers (tamsulosin, alfuzosin, doxazosin, silodosin)
Severe Symptoms (IPSS ≥20) or Enlarged Prostate:
- First-line: Combination therapy with alpha blocker + 5-alpha reductase inhibitor 1
- 5-alpha reductase inhibitors (finasteride, dutasteride) reduce risk of acute urinary retention by 57% and BPH-related surgery by 55% 1
- Finasteride indicated to improve symptoms, reduce risk of acute urinary retention, and reduce need for surgery 5
- Reassess at 3 months for 5-alpha reductase inhibitors 1
Failed Medical Therapy or Complications:
- Surgical interventions:
Treatment Evaluation and Follow-up
- Reassess IPSS at 2-4 weeks for alpha blockers and 3 months for 5-alpha reductase inhibitors 1
- Consider treatment changes if:
- Patient reports dissatisfaction despite IPSS improvement
- IPSS has not improved despite patient reporting satisfaction
- IPSS has deteriorated 1
- Annual follow-up for patients on watchful waiting 1
Important Complications Requiring Prompt Intervention
- Acute urinary retention
- Chronic urinary retention
- Recurrent urinary tract infections
- Bladder stones
- Renal insufficiency
- Hematuria 1
Common Pitfalls to Avoid
- Relying solely on IPSS without patient discussion: IPSS is not a replacement for clinical judgment 1
- Ignoring bother score: Symptom scores alone don't fully capture impact on quality of life 1
- Overlooking non-BPH causes of symptoms: When LUTS and normal Qmax are present 1
- Using urethrocystoscopy in initial evaluation: Not recommended unless specific risk factors are present 3
- Failing to consider prostate size in treatment selection: Larger prostates respond better to 5-alpha reductase inhibitors or combination therapy 1
By following this structured approach to diagnosis and treatment, clinicians can effectively manage BPH while prioritizing improvements in patients' quality of life and reducing morbidity associated with disease progression.