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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

The first-line treatment for symptomatic BPH is medical therapy with alpha blockers for rapid symptom relief, with 5-alpha reductase inhibitors added for patients with enlarged prostates (>30cc), and surgical intervention reserved for patients who have failed medical therapy or developed complications. 1

Medical Therapy Options

First-Line Therapy

• Alpha blockers:
  • Provide rapid symptom relief
  • Options include:
    • Uroselective: Tamsulosin, Alfuzosin (preferred due to better tolerability) 1, 2
    • Non-uroselective: Doxazosin, Terazosin (higher risk of cardiovascular side effects) 2, 3
  • Advantages of uroselective agents:
    • No dose titration required
    • Once-daily dosing
    • Fewer cardiovascular side effects 2
  • Common side effects:
    • Tamsulosin: Ejaculatory dysfunction
    • Alfuzosin: Mild hypotension 4, 2

For Enlarged Prostates (>30cc)

• 5-alpha reductase inhibitors (5ARIs):
  • Options:
    • Finasteride 5mg daily 5
    • Dutasteride 0.5mg daily 6
  • Benefits:
    • Reduce prostate volume
    • Reduce risk of acute urinary retention by 67%
    • Reduce need for BPH-related surgery by 64% 1, 5, 6
  • Side effects:
    • Sexual dysfunction (decreased libido, erectile dysfunction)
    • Generally reversible and uncommon after first year 1
  • Important monitoring:
    • PSA levels (5ARIs reduce PSA by ~50% after 12 months)
    • Establish new PSA baseline after 3-6 months 1

Combination Therapy

• Alpha blocker + 5ARI:
  • Indicated for:
    • Patients with large prostates and moderate-severe symptoms
    • Reducing risk of symptomatic progression 1, 5, 6
  • Specific FDA-approved combinations:
    • Finasteride with doxazosin 5
    • Dutasteride with tamsulosin 6

Additional Medical Options

• Beta-3-agonists (e.g., mirabegron):

  • For moderate-severe predominant storage symptoms
  • Can be combined with alpha blockers 1

• Anticholinergics:

  • For moderate-severe predominant storage symptoms
  • Can be used alone or with alpha blockers 1

• PDE-5 inhibitors (e.g., tadalafil 5mg daily):

  • Particularly useful for patients with concomitant erectile dysfunction
  • Should not be combined with alpha blockers due to hypotension risk 1

Surgical Interventions

Indications for Surgery

Surgery is recommended for patients with: 7, 1

• Refractory urinary retention (failing at least one catheter removal attempt)
• Recurrent UTIs due to BPH
• Recurrent gross hematuria due to BPH
• Renal insufficiency due to BPH
• Bladder stones due to BPH
• Failed medical therapy

Surgical Options

1. Transurethral Resection of the Prostate (TURP):

   • Gold standard surgical treatment 1, 8

2. Minimally Invasive Procedures:

   • Laser procedures:
     • HoLEP (Holmium Laser Enucleation of the Prostate)
     • Greenlight laser
     • Thulium laser 1, 8
   • Prostatic Urethral Lift (PUL) 1, 8

3. Open Prostatectomy:

   • For very large prostates 1

Management Algorithm

1. Initial Assessment:

   • Quantify symptom severity using International Prostate Symptom Score (IPSS)
   • Perform digital rectal examination to assess prostate size
   • Consider PSA measurement if life expectancy >10 years
   • Measure post-void residual volume
   • Perform urinalysis to rule out infection

2. Treatment Selection:

   • Mild symptoms with minimal bother: Lifestyle modifications
   • Moderate-severe symptoms:
     • Normal-sized prostate (<30cc): Alpha blocker monotherapy
     • Enlarged prostate (>30cc): Alpha blocker + 5ARI combination
     • Predominant storage symptoms: Consider adding beta-3-agonist or anticholinergic
     • Concomitant erectile dysfunction: Consider PDE-5 inhibitor (not with alpha blockers)

3. Follow-up:

   • Evaluate response within 4-12 weeks
   • Reassess IPSS score
   • Consider PVR and uroflowmetry
   • Annual follow-up if treatment successful

4. Consider Surgery If:

   • Medical therapy fails
   • Complications develop (retention, recurrent UTIs, hematuria, renal insufficiency, bladder stones)

Important Considerations and Pitfalls

• 5ARIs are ineffective in patients without prostate enlargement 1
• Combining tadalafil with alpha blockers increases hypotension risk 1
• Alpha blockers can cause orthostatic hypotension - advise patients to rise slowly from sitting/lying positions 4
• 5ARIs reduce PSA by ~50% - establish new baseline after 3-6 months of treatment 1
• For patients with urinary retention, concomitant administration of an alpha blocker prior to catheter removal may improve success 7
• Post-void dribbling can be managed with pelvic floor exercises and urethral milking technique 1
• Inform ophthalmologists about alpha blocker use before cataract surgery 4

By following this evidence-based approach to BPH management, clinicians can effectively address symptoms, improve quality of life, and reduce the risk of complications associated with this common condition.