How to diagnose and treat suspected Benign Prostatic Hyperplasia (BPH)?

Diagnosis of Benign Prostatic Hyperplasia (BPH)

BPH diagnosis requires a combination of symptom assessment, physical examination including digital rectal examination, and basic laboratory tests to rule out other conditions causing similar symptoms. 1

Diagnostic Criteria and Symptoms

BPH primarily presents with lower urinary tract symptoms (LUTS) that can be categorized as:

• Storage symptoms:

  • Urinary frequency
  • Nocturia (waking at night to urinate)
  • Urgency
  • Incontinence

• Voiding symptoms:

  • Weak urinary stream
  • Hesitancy
  • Intermittency
  • Straining to void
  • Prolonged voiding
  • Incomplete emptying sensation

Essential Diagnostic Tests

1. Medical history and symptom assessment:

   • International Prostate Symptom Score (IPSS) questionnaire to quantify symptom severity
   • Assessment of symptom bother and impact on quality of life

2. Physical examination:

   • Digital rectal examination (DRE) to:
     • Estimate prostate size
     • Assess prostate morphology
     • Rule out prostate cancer

3. Laboratory tests:

   • Urinalysis to exclude UTI, hematuria, glycosuria, and proteinuria
   • Optional: PSA testing (particularly if considering 5-ARI therapy)

Optional Diagnostic Tests

These tests are not required for initial diagnosis but may help guide treatment decisions:

• Post-void residual (PVR) measurement:

  • Provides objective assessment of bladder emptying
  • Large PVR volumes (>350 ml) may indicate bladder dysfunction

• Uroflowmetry:

  • Measures urinary flow rate
  • Qmax <10 ml/sec suggests urodynamic obstruction
  • Men with normal flow rates but significant symptoms may have non-BPH causes

• Prostate volume assessment:

  • Via transrectal or transabdominal ultrasound
  • Important when considering 5-ARI therapy
  • Prostate size >30cc suggests benefit from 5-ARI therapy

Treatment Algorithm

First-Line Treatment Options

1. Alpha-blockers (for rapid symptom relief):

   • Tamsulosin 0.4 mg once daily, taken 30 minutes after the same meal each day 2
   • Alfuzosin (taken with food and with the same meal each day) 3
   • Side effects include orthostatic hypotension, dizziness, ejaculatory dysfunction

2. 5-alpha reductase inhibitors (5-ARIs) (for enlarged prostates):

   • Finasteride for prostates >30cc or PSA >1.5ng/mL
   • Reduces prostate volume by 20-30%
   • Reduces risk of acute urinary retention and need for surgery 4
   • Side effects include sexual dysfunction

3. Combination therapy:

   • Alpha-blocker + 5-ARI for men with enlarged prostates
   • More effective than either medication alone for symptom relief and preventing disease progression 1
   • Higher risk of side effects

4. Other medical options:

   • PDE5 inhibitors (tadalafil 5mg daily) for patients with concurrent erectile dysfunction
   • Anticholinergics or beta-3 agonists for persistent storage symptoms

Surgical Treatment

Surgery is recommended for:

• Patients with refractory urinary retention who have failed catheter removal attempts
• Renal insufficiency due to BPH
• Recurrent UTIs due to BPH
• Recurrent gross hematuria due to BPH
• Bladder stones due to BPH 5

Transurethral resection of the prostate (TURP) remains the benchmark surgical therapy for BPH 1.

Follow-up and Monitoring

• Evaluate response to treatment 4-12 weeks after initiation
• Follow-up should include IPSS score reassessment and evaluation of medication side effects
• Schedule follow-up at 4 weeks for alpha blockers and 3-6 months for 5-ARIs 1

Common Pitfalls and Caveats

1. Symptom severity doesn't always correlate with bother:

   • Treatment decisions should be based on how bothered the patient is by symptoms, not just symptom score 5

2. Alpha-blockers and cataract surgery:

   • Inform ophthalmologists about alpha-blocker use before cataract surgery due to risk of intraoperative floppy iris syndrome 1

3. Prostate size alone should not determine treatment:

   • It is not reasonable to decide whether to treat based solely on prostate size 6

4. Bladder dysfunction contribution:

   • A large part of BPH symptomatology may be explained by bladder dysfunction, which tends to be overlooked 6

5. Post-void residual variability:

   • PVR has significant test-retest variability, limiting its predictive value 6

By following this diagnostic approach and treatment algorithm, clinicians can effectively diagnose and manage BPH, improving patients' quality of life while reducing the risk of complications.