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 added for patients with prostate size >30cc, and surgical interventions considered for patients who have failed medical therapy or developed complications. 1

Medical Therapy Options

First-Line Treatment

• Alpha blockers: Provide rapid symptom relief
  • Options include tamsulosin, alfuzosin, doxazosin, and terazosin
  • Tamsulosin and alfuzosin have better tolerability profiles compared to doxazosin and terazosin 2
  • Tamsulosin is associated with ejaculatory dysfunction, while alfuzosin has more hypotensive side effects 2
  • Alpha blockers improve symptoms by 20-65% and increase urinary flow by 1-4.3 ml/s 3

Second-Line and Combination Treatments

• 5-alpha reductase inhibitors (5ARIs):

  • Indicated for patients with enlarged prostates (>30cc) 1
  • Options include finasteride 5mg daily and 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 and improve symptoms over time
  • Sexual side effects include decreased libido and erectile dysfunction 1, 4

• Combination therapy (alpha blocker + 5ARI):

  • Particularly effective for patients with large prostate and median lobe hypertrophy 1
  • Indicated to reduce risk of symptomatic progression of BPH 4
  • More effective than either medication alone but with increased side effects 4

• Additional medical options:

  • PDE-5 inhibitors: Tadalafil 5mg daily can improve BPH symptoms, particularly for patients with concomitant erectile dysfunction 1

    • Caution: Should not be combined with alpha blockers due to risk of hypotension 1

  • Beta-3-agonists (mirabegron): May be offered for moderate to severe predominate storage LUTS, in combination with an alpha blocker 1

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

Surgical Interventions

Surgical treatment should be considered when patients:

• Have failed medical therapy
• Develop recurrent urinary retention
• Experience recurrent UTIs
• Develop renal insufficiency
• Have recurrent gross hematuria
• Develop bladder stones due to BPH 1

Surgical Options

• Transurethral Resection of the Prostate (TURP): Gold standard surgical treatment 1, 5
• Minimally invasive procedures:
  • Laser procedures: HoLEP, Greenlight, thulium laser 1, 5
  • Prostatic urethral lift (PUL) 1, 5
• Open prostatectomy: For very large 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
• Monitor for complications including acute urinary retention, recurrent UTIs, bladder stones, and renal insufficiency 1
• For patients on 5ARIs:
  • Monitor PSA (5ARIs reduce PSA by approximately 50% after 12 months)
  • Establish new PSA baseline after 3-6 months of treatment 1
  • Monitor sexual function, including erectile and ejaculatory function 1

Important Considerations and Pitfalls

• Sexual function impact: Consider erectile function when selecting BPH treatment, as 5ARIs may cause sexual side effects 1, 4
• Medication interactions: Avoid combining tadalafil with alpha blockers due to hypotension risk 1
• Treatment efficacy: 5ARIs are ineffective in patients without prostate enlargement 1
• PSA monitoring: Failure to establish a new PSA baseline after starting 5ARI therapy can lead to inaccurate prostate health monitoring 1
• Disease progression: Men with larger glands may benefit from early intervention with 5ARIs despite potential sexual side effects 1
• Lifestyle modifications: Recommend limiting evening fluid intake, reducing caffeine and alcohol consumption, and avoiding medications that worsen symptoms (decongestants, antihistamines) 1
• Pelvic floor exercises: Kegel exercises combined with urethral milking technique can help manage post-void dribbling 1