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

Treatment Options 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

Treatment Algorithm for BPH

Lifestyle Modifications (First-line for mild 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
• Moderate alcohol intake (up to 2 drinks per day)
• Regular physical exercise
• Weight loss for overweight or obese patients 1

Medical Therapy (For moderate symptoms)

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

   • Mechanism: Relax prostatic smooth muscle 2
   • Benefits: Improve symptoms by 4-6 points on the AUA Symptom Index within 4 weeks 1
   • Best for: Quick symptom relief

2. 5-alpha reductase inhibitors (5-ARIs) (e.g., finasteride, dutasteride)

   • Mechanism: Reduce prostate size over time 3
   • Indications: Prostates larger than 30cc 1
   • Benefits:
     • Improve symptoms
     • Reduce risk of acute urinary retention
     • Reduce risk of needing surgery including TURP 4
   • Side effects: Sexual dysfunction (impotence 8.1%, decreased libido 6.4%, ejaculation disorders) 4

3. Combination therapy (Alpha-blocker + 5-ARI)

   • Indication: Reduce risk of symptomatic progression of BPH 4
   • Best for: Large prostates with moderate to severe symptoms 1
   • Side effects: Higher incidence of asthenia, postural hypotension, peripheral edema, dizziness, and sexual dysfunction 4

Surgical Treatment (For severe symptoms or failed medical therapy)

1. Transurethral Resection of the Prostate (TURP)

   • Gold standard surgical treatment 1, 5
   • Requires general or spinal anesthesia and hospital stay
   • Complications: 1% risk of urinary incontinence, potential TURP syndrome (dilutional hyponatremia) 1

2. Alternative surgical options

   • Minimally invasive procedures
   • Transurethral incision of the prostate (TUIP)
   • Laser procedures (HoLEP, Greenlight, thulium laser) 5
   • Prostatic urethral lift (PUL) 5

3. Prostatic stents

   • Reserved for high-risk patients with urinary retention 1
   • Associated with significant complications

When to Choose Each Treatment Option

Watchful Waiting

• For patients with mild symptoms (low IPSS score)
• No significant impact on quality of life

Medical Therapy

• For moderate symptoms or when symptoms affect quality of life
• Choose alpha-blockers for rapid symptom relief
• Choose 5-ARIs for large prostates (>30cc) and long-term management 1
• Choose combination therapy for large prostates with moderate-severe symptoms and risk of progression 4

Surgical Intervention

• For patients who have failed medical therapy
• For moderate-to-severe symptoms unresponsive to medications
• For complications such as:
  • Acute urinary retention
  • Recurrent UTIs
  • Bladder stones
  • Renal insufficiency 1

Monitoring and Follow-up

• Evaluate patients 4-12 weeks after initiating treatment 1
• Assessment should include:
  • International Prostate Symptom Score (IPSS)
  • Post-void residual (PVR)
  • Uroflowmetry to evaluate obstruction improvement 1
• Maintain a bladder diary for 3 days to document fluid intake and voiding patterns

Important Considerations and Pitfalls

• Progression risk: Untreated BPH increases risk of acute urinary retention, particularly in men over 70 1
• Medication efficacy: Medical therapies provide adequate symptomatic relief with fewer adverse events than surgery, but are not as effective as surgical treatments 1
• 5-ARI side effects: Be aware of potential sexual side effects with finasteride, which are most common in the first year of treatment 4
• Combination therapy complications: Higher incidence of adverse effects compared to monotherapy 4
• Prostate cancer risk: Finasteride is not approved for the prevention of prostate cancer; the PCPT trial showed higher incidence of high-grade prostate cancer (Gleason 8-10) in men treated with finasteride 4