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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

The treatment of BPH should follow a structured algorithm based on symptom severity, with watchful waiting for mild symptoms, medical therapy for moderate symptoms, and surgical interventions for severe symptoms or complications. 1

Treatment Algorithm

Lifestyle Modifications

• Reduce overall fluid intake by 25% to decrease urinary frequency and urgency
• 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

Medical therapy is indicated for patients with moderate symptoms:

1. Alpha-blockers

   • First-line treatment for moderate symptoms
   • Examples: alfuzosin, doxazosin, tamsulosin, terazosin
   • Mechanism: Relax prostatic smooth muscle
   • Efficacy: Improve symptoms by 4-6 points on the AUA Symptom Index within 4 weeks
   • Side effects: Dizziness (17.7-23.2%), postural hypotension (16.7-17.8%), asthenia (15.7-16.8%) 1, 2

2. 5-alpha reductase inhibitors (5-ARIs)

   • Examples: finasteride, dutasteride
   • Indicated for prostates larger than 30cc
   • Mechanism: Reduce prostate size over time
   • Benefits: Improve symptoms, reduce risk of acute urinary retention, decrease need for surgery
   • FDA-approved indications for finasteride:
     • Improve symptoms
     • Reduce risk of acute urinary retention
     • Reduce risk of surgery including TURP and prostatectomy 1, 3
   • Side effects: Sexual dysfunction (impotence 18.5%, decreased libido 10%, abnormal ejaculation 7.2%) 3

3. Combination Therapy

   • Alpha-blocker + 5-ARI
   • Indicated to reduce risk of symptomatic progression of BPH
   • Most effective for large prostates with moderate to severe symptoms
   • Higher incidence of side effects: abnormal ejaculation (14.1%), impotence (22.6%), dizziness (23.2%) 1, 3

Surgical Treatment

Surgical treatment is recommended 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 1

Surgical Options:

1. Transurethral Resection of the Prostate (TURP)

   • Gold standard surgical treatment
   • Involves removal of the prostate's inner portion via endoscope
   • Usually performed under general or spinal anesthesia
   • Requires hospital stay
   • Complications: 1% risk of urinary incontinence, potential TURP syndrome (dilutional hyponatremia) 1

2. Other Surgical Options

   • Minimally invasive procedures
   • Transurethral incision of the prostate (TUIP)
   • Laser procedures (HoLEP, Greenlight, thulium laser)
   • Prostatic urethral lift (PUL) 1, 4
   • Prostatic stents (reserved for high-risk patients with urinary retention) 1

Monitoring and Follow-up

• Evaluate patients 4-12 weeks after initiating treatment
• 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 1

Important Considerations and Pitfalls

Risk of Disease Progression

• Untreated BPH can increase risk of acute urinary retention, particularly in men over 70 years old
• Medical therapies are not as effective as surgical treatments but provide adequate symptomatic relief with fewer adverse events 1

Medication Side Effects

• Be aware of sexual side effects with 5-ARIs (impotence, decreased libido, ejaculation disorders)
• Alpha-blockers can cause dizziness, postural hypotension, and asthenia
• Combination therapy has higher incidence of side effects than either monotherapy 3

High-Grade Prostate Cancer Risk

• Finasteride has been associated with a slightly higher incidence of high-grade prostate cancer (Gleason score 8-10) compared to placebo (1.8% vs 1.1%)
• Finasteride is not approved for the prevention of prostate cancer 3

Treatment Selection

The choice between medical and surgical therapy should be based on:

• Symptom severity
• Prostate size
• Patient preference
• Risk of progression
• Comorbidities 1, 4