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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

The treatment of BPH should follow a stepwise approach starting with medical therapy (alpha blockers as first-line for rapid symptom relief, adding 5-alpha reductase inhibitors for enlarged prostates >30cc), progressing to surgical interventions when medical therapy fails or complications develop. 1

Initial Assessment and Medical Therapy

First-Line Medical Therapy

• Alpha blockers (tamsulosin, alfuzosin, doxazosin, terazosin)
  • Provide rapid symptom relief by relaxing prostatic smooth muscle 1, 2
  • Work regardless of prostate size, symptom severity, or obstruction degree 2
  • Improve symptoms by 20-65% and increase urinary flow by 1-4.3 ml/s 2
  • Tamsulosin and alfuzosin have better tolerability profiles than doxazosin/terazosin 2
  • Common side effects: dizziness, rhinitis, abnormal ejaculation 3

Second-Line/Combination Medical Therapy

• 5-alpha reductase inhibitors (5ARIs) (finasteride, dutasteride)

  • Indicated for men with enlarged prostates >30cc 1
  • Finasteride reduces risk of acute urinary retention by 67% and BPH-related surgery by 64% 1, 4
  • Takes 3-6 months for full effect 1
  • Side effects: sexual dysfunction (decreased libido, erectile dysfunction, ejaculation disorders) 4

• Combination therapy (alpha blocker + 5ARI)

  • Particularly effective for large prostates and median lobe hypertrophy 1
  • Reduces risk of symptomatic progression of BPH 4
  • Higher incidence of side effects compared to monotherapy 4

• Additional medical options:

  • Beta-3-agonists (mirabegron): For moderate to severe storage LUTS, can be combined with alpha blockers 1
  • Anticholinergics: For storage symptoms, can be used alone or with alpha blockers 1
  • PDE-5 inhibitors (tadalafil 5mg daily): Improves symptoms, especially with concurrent erectile dysfunction 1
    • Caution: Do not combine with alpha blockers due to hypotension risk 1

Surgical Interventions

Indicated when patients have 1:

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

Surgical Options

1. Transurethral Resection of the Prostate (TURP)

   • Gold standard surgical treatment 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, 5

Lifestyle Modifications

• Limit evening fluid intake
• Reduce caffeine and alcohol consumption
• Avoid medications that worsen symptoms (decongestants, antihistamines)
• Pelvic floor exercises for post-void dribbling
• Rise slowly from sitting/lying positions 1

Monitoring and Follow-up

• Evaluate response to therapy within 4-12 weeks of treatment initiation 1
• Reassess IPSS score; consider PVR and uroflowmetry during follow-up 1
• Annual follow-up if treatment is successful 1
• For patients on 5ARIs:
  • Monitor sexual function
  • Establish new PSA baseline after 3-6 months (5ARIs reduce PSA by ~50% after 12 months) 1
  • Regular monitoring of post-void residual volume to detect early signs of urinary retention 1

Important Considerations and Pitfalls

• Alpha blockers provide faster symptom relief but don't prevent disease progression 2
• 5ARIs are ineffective in patients without prostate enlargement 1
• Tamsulosin shows only moderate improvement in symptoms compared to placebo (12-16% improvement) 3
• Higher doses of tamsulosin (0.8mg) significantly increase adverse effects (75% of men) 3
• Doxazosin and terazosin are no longer recommended for hypertension treatment due to increased cardiovascular side effects 2
• Consider erectile function when selecting treatment, as 5ARIs may cause sexual side effects 1, 4

The treatment approach should be guided by symptom severity, prostate size, patient preference, and the presence of complications, with medical therapy as the initial approach for most patients and surgery reserved for those with complications or failed medical management.