What are the recommended steps for diagnosing and treating Benign Prostatic Hyperplasia (BPH)?

Diagnosing and Managing Benign Prostatic Hyperplasia (BPH)

A thorough evaluation for BPH requires medical history, symptom assessment using the AUA Symptom Index or IPSS, physical examination with digital rectal examination, urinalysis, and selective PSA testing as recommended by the American Urological Association. 1

Diagnostic Approach

Initial Assessment

• Symptom Assessment: Use validated tools like the AUA Symptom Index or International Prostate Symptom Score (IPSS) to classify severity:

  • Mild (0-7 points)
  • Moderate (8-19 points)
  • Severe (20-35 points) 1

• Physical Examination:

  • Digital rectal examination (DRE) is mandatory to:
    • Exclude locally advanced prostate cancer
    • Estimate prostate size 1
  • Assess for bladder distention or neurologic impairment 2

• Laboratory Testing:

  • Urinalysis: Required to screen for hematuria, rule out UTI, and exclude other conditions causing similar symptoms 1
  • PSA measurement: Should be offered to patients with at least 10-year life expectancy where knowledge of prostate cancer would change management 1

Additional Testing (When Indicated)

• Frequency-volume charts (voiding diary): Particularly useful when nocturia is the dominant symptom 1
• Uroflowmetry, post-void residual urine measurement, pressure-flow studies: Consider before invasive/surgical therapy or in specific clinical scenarios 1

Treatment Algorithm

1. Mild Symptoms (IPSS 0-7)

• Watchful waiting with annual follow-up is the standard recommendation 1, 3
  • The risks of medical therapy outweigh the benefits in this group

2. Moderate Symptoms (IPSS 8-19) with Bother

• Alpha-blockers as first-line therapy 1, 4
  • Options include tamsulosin, alfuzosin, and silodosin
  • Tamsulosin dosing: 0.4 mg once daily, approximately 30 minutes after the same meal each day 5
  • Can increase to 0.8 mg if no response after 2-4 weeks 5
  • Provides rapid symptom relief (within 3-5 days) by relaxing smooth muscle in the prostate and bladder neck 1, 4
  • Average improvement of 3 points on the AUA Symptom Index 1

3. Severe Symptoms (IPSS ≥20) or Large Prostates

• 5-alpha reductase inhibitors (finasteride, dutasteride) 1
  • Indicated for symptomatic BPH in men with enlarged prostate 6
  • Reduces prostate size
  • Reduces risk of acute urinary retention by 57% and BPH-related surgery by 55% 1
  • Consider combination therapy with alpha-blockers for optimal results 1, 6
  • Finasteride with doxazosin is specifically indicated to reduce risk of symptomatic BPH progression 6

4. Surgical Interventions

• Indicated when:
  • Medical therapy fails
  • Patient preference
  • Complications develop (urinary retention, renal insufficiency, recurrent UTIs, bladder stones) 1, 7
• Options include:
  • Transurethral resection of prostate (TURP)
  • Transurethral incision of prostate
  • Open prostatectomy
  • Minimally invasive procedures like Transurethral Microwave Therapy (TUMT) 1

Monitoring and Follow-up

• After initiating alpha-blockers: Follow-up at 2-4 weeks 1
• After initiating 5-alpha reductase inhibitors: Follow-up at 3 months 1
• Follow-up should include:
  • IPSS score
  • Quality of life (QoL) score
  • Physical examination
  • Urinalysis 1
• PSA monitoring:
  • Finasteride and dutasteride typically decrease PSA by approximately 50% within 6-12 months 1
  • A PSA increase from nadir of ≥0.3 ng/ml should trigger biopsy consideration 1

Important Caveats

• Rule out prostate cancer before initiating BPH treatment, as medications can mask cancer progression and affect PSA interpretation 1
• Dietary supplements (saw palmetto, pygeum, cernilton, beta sitosterols) and acupuncture are not recommended for BPH management 2
• A change of 2-3 points on the AUA Symptom Index is considered clinically meaningful 1
• Tamsulosin should not be used with strong CYP3A4 inhibitors like ketoconazole 5