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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

Alpha blockers should be used as first-line therapy for rapid symptom relief in BPH, with 5-alpha reductase inhibitors (5ARIs) added for patients with prostate size >30cc, and surgical interventions considered for those who have failed medical therapy or have complications. 1

Medical Therapy Options

First-Line Therapy

• Alpha blockers: Provide rapid symptom relief
  • Options include tamsulosin, alfuzosin, doxazosin, and terazosin
  • Tamsulosin and alfuzosin have better tolerability profiles than doxazosin or terazosin 2
  • Tamsulosin is associated with ejaculatory dysfunction while alfuzosin has more hypotensive side effects 2
  • Effectiveness is similar across alpha blockers, with improvement in symptoms by 12-16% and peak urine flow by approximately 1.1 mL/sec 3

Second-Line/Combination Therapy

• 5-alpha reductase inhibitors (5ARIs):

  • Indicated for patients with enlarged prostates (>30cc) 1
  • Options include finasteride 5mg daily or dutasteride 0.5mg daily
  • Reduce risk of acute urinary retention by 67% and need for BPH-related surgery by 64% 1, 4
  • Reduce prostate volume over time
  • Sexual side effects include decreased libido and erectile dysfunction (most common in first year) 4
  • Reduce PSA by approximately 50% after 12 months (establish new baseline after 3-6 months) 1

• Combination therapy (alpha blocker + 5ARI):

  • Particularly effective for patients with large prostate and median lobe hypertrophy 1
  • Finasteride with doxazosin reduces risk of symptomatic progression of BPH 4
  • May have increased side effects compared to monotherapy 4

Additional Medical Options

• Beta-3-agonists (e.g., mirabegron):

  • Option for patients with moderate to severe predominant storage LUTS
  • Can be used in combination with alpha blockers 1

• Anticholinergic agents:

  • Can be used alone or with alpha blockers for patients with moderate to severe predominant storage LUTS 1

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

  • Improve BPH symptoms, particularly beneficial for patients with concomitant erectile dysfunction
  • Should NOT be combined with alpha blockers due to risk of hypotension 1

Surgical Interventions

Consider surgical intervention when patients have:

• Failed medical therapy
• Recurrent urinary retention
• Recurrent UTIs
• Renal insufficiency
• Recurrent gross hematuria
• Bladder stones due to BPH 1

Surgical Options

1. Transurethral Resection of the Prostate (TURP):

   • Gold standard for surgical treatment of BPH 1, 5

2. Minimally invasive procedures:

   • Laser procedures: HoLEP, Greenlight, thulium laser 1, 5
   • Prostatic urethral lift (PUL) 1, 5

3. Open prostatectomy:

   • For very large prostates 1

4. Transurethral incision of the prostate:

   • Option for smaller prostates 1

Monitoring and Follow-up

• Evaluate response to therapy within 4-12 weeks after initiating treatment 1
• Reassess IPSS score and consider PVR and uroflowmetry during follow-up 1
• Annual follow-up if treatment is successful 1
• Monitor for complications (acute urinary retention, UTIs, bladder stones, renal insufficiency) 1
• Regular monitoring of post-void residual volume to detect early signs of urinary retention 1
• For patients on 5ARIs, establish new PSA baseline after 3-6 months (PSA typically reduced by 50%) 1

Lifestyle Modifications

• Limit evening fluid intake
• Reduce caffeine and alcohol consumption
• Avoid medications that worsen symptoms (decongestants, antihistamines)
• Rise slowly from sitting or lying positions (especially if taking alpha blockers)
• Consider pelvic floor exercises (Kegel) with urethral milking technique for post-void dribbling 1

Important Considerations and Pitfalls

• 5ARIs are ineffective in patients without prostate enlargement 1
• Combining tadalafil with alpha blockers increases risk of hypotension 1
• Sexual side effects are more common with 5ARIs than alpha blockers 1, 4
• Alpha blockers provide more rapid symptom relief than 5ARIs or plant extracts 6
• Neglecting to establish a new PSA baseline after starting 5ARI therapy can lead to inaccurate monitoring 1
• Overlooking the progressive nature of BPH in men with larger glands who may benefit from early intervention with 5ARIs 1