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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

Medical therapy should be the first-line approach for most patients with symptomatic BPH, with surgical options reserved for those who fail medical management or have specific complications. 1

Initial Assessment and Diagnosis

• Use International Prostate Symptom Score (IPSS) to quantify symptom severity
• Perform digital rectal examination to confirm prostatic enlargement
• Conduct urinalysis to rule out infection and hematuria
• Consider PSA measurement if life expectancy >10 years
• Measure post-void residual (PVR) volume

Medical Treatment Options

First-Line Therapy

• Alpha blockers (rapid symptom relief within 3-5 days):
  • Tamsulosin, alfuzosin, silodosin (selective alpha-1A blockers)
  • Doxazosin, terazosin (non-selective alpha blockers, also useful for patients with hypertension)
  • Side effects: dizziness, postural hypotension, abnormal ejaculation 1

For Enlarged Prostates (>30cc)

• 5-alpha reductase inhibitors (5ARIs):
  • Finasteride 5mg daily or dutasteride 0.5mg daily
  • Reduces risk of acute urinary retention by 67%
  • Reduces need for BPH-related surgery by 64%
  • Takes 6-12 months for maximum effect
  • Side effects: sexual dysfunction (decreased libido, erectile dysfunction) 1, 2

Combination Therapy

• Alpha blocker + 5ARI:
  • Particularly effective for patients with large prostates and moderate-severe symptoms
  • Finasteride + doxazosin reduces risk of symptomatic progression of BPH 1, 2
  • Side effects: increased risk of sexual dysfunction, asthenia, dizziness 2

Additional Medical Options

• PDE-5 inhibitors:

  • Tadalafil 5mg daily improves BPH symptoms
  • Particularly useful for patients with concomitant erectile dysfunction
  • Should not be combined with alpha blockers due to risk of hypotension 1

• For storage symptoms:

  • Beta-3-agonists (mirabegron) or anticholinergics can be added to alpha blockers
  • Useful for patients with predominant storage symptoms 1

Surgical and Minimally Invasive Options

Indicated when patients have:

• Failed medical therapy
• Recurrent urinary retention
• Recurrent UTIs
• Renal insufficiency
• Recurrent gross hematuria
• Bladder stones due to BPH 3, 1

Surgical Options

• Transurethral Resection of the Prostate (TURP):

  • Gold standard surgical treatment
  • Higher risk of bleeding compared to newer modalities 3, 1

• Laser Enucleation:

  • Holmium laser enucleation (HoLEP) or thulium laser enucleation (ThuLEP)
  • Suitable for all prostate sizes
  • Better coagulative properties than TURP
  • Recommended for patients on anticoagulation therapy 3

• Photoselective Vaporization of the Prostate (PVP):

  • Safe for patients on anticoagulation
  • May require longer catheterization and irrigation 3

Minimally Invasive Options

• Water Vapor Thermal Therapy:

  • For prostates <80g
  • Preserves erectile and ejaculatory function
  • Limited long-term efficacy data 3

• Transurethral Needle Ablation (TUNA):

  • Not recommended by current guidelines 3

• Prostatic Urethral Lift (PUL):

  • Minimally invasive option 1

Treatment Algorithm

1. Mild symptoms with minimal bother:

   • Lifestyle modifications (limit evening fluids, reduce caffeine/alcohol)
   • Watchful waiting with annual follow-up

2. Moderate to severe symptoms:

   • Small prostate (<30cc): Alpha blocker monotherapy
   • Enlarged prostate (>30cc):
     • Alpha blocker for immediate relief
     • Add 5ARI for long-term management
     • Consider combination therapy

3. Predominant storage symptoms:

   • Alpha blocker + anticholinergic or beta-3-agonist

4. Concomitant erectile dysfunction:

   • Consider PDE-5 inhibitor (tadalafil)

5. Patients on anticoagulation:

   • If surgery needed, consider HoLEP, ThuLEP, or PVP

6. Failed medical therapy or complications:

   • Proceed to appropriate surgical intervention based on prostate size and comorbidities

Monitoring and Follow-up

• Evaluate response to therapy within 4-12 weeks
• Reassess IPSS score
• Monitor for complications (urinary retention, UTIs)
• Annual follow-up if treatment successful
• For patients on 5ARIs, establish new PSA baseline after 3-6 months (PSA typically reduced by 50%) 1, 2

Common Pitfalls to Avoid

• Using 5ARIs in patients with small prostates (<30cc) is ineffective
• Combining tadalafil with alpha blockers increases risk of hypotension
• Neglecting to establish new PSA baseline after starting 5ARI therapy
• Overlooking the progressive nature of BPH in men with larger prostates who may benefit from early 5ARI therapy
• Failing to counsel patients about potential sexual side effects of 5ARIs