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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

The most effective treatment approach for BPH follows a structured algorithm based on symptom severity, with watchful waiting for mild symptoms, medical therapy for moderate symptoms, and surgical interventions for severe symptoms or complications. 1

Initial Assessment and Stratification

• Use the International Prostate Symptom Score (IPSS) to assess baseline symptoms and monitor response to treatment
• Maintain a bladder diary for 3 days to document fluid intake and voiding patterns
• Evaluate prostate size (prostates larger than 30cc respond better to certain medications)

Treatment Options by Severity

Lifestyle Modifications (For All Patients)

• Reduce overall fluid intake by 25% to decrease urinary frequency and urgency
• Adopt a diet rich in fruits and vegetables and low in saturated fats
• Moderate alcohol intake (up to 2 drinks per day)
• Regular physical exercise
• Weight loss for overweight or obese patients

Medical Therapy

1. Alpha-blockers (e.g., alfuzosin, doxazosin, tamsulosin, terazosin):

   • First-line for moderate symptoms
   • Improve symptoms by 4-6 points on the AUA Symptom Index within 4 weeks
   • Tamsulosin has specificity for alpha-1A receptors and lacks significant effects on blood pressure 1, 2

2. 5-alpha reductase inhibitors (5-ARIs) (e.g., finasteride, dutasteride):

   • Indicated for prostates larger than 30cc
   • Reduce prostate size over time
   • Improve symptoms and reduce risk of acute urinary retention
   • Decrease need for surgery
   • Finasteride reduces serum DHT by approximately 70% with daily dosing 1, 3
   • Requires 6 months to assess effectiveness and 12 months for maximum prostate shrinkage 2

3. Combination Therapy:

   • Alpha-blocker + 5-ARI combination is indicated to reduce risk of BPH progression
   • Particularly effective for large prostates with moderate to severe symptoms
   • Finasteride with doxazosin reduces risk of symptomatic progression of BPH 1, 3
   • May have increased side effects including asthenia, postural hypotension, decreased libido, and sexual dysfunction 3

Surgical Interventions

1. Transurethral Resection of the Prostate (TURP):

   • Gold standard for surgical therapy
   • Indicated for patients with moderate-to-severe symptoms who have failed medical therapy
   • Also for acute urinary retention or other BPH-related complications
   • Complications include 1% risk of urinary incontinence and potential TURP syndrome 1, 4

2. Alternative Surgical Options:

   • Transurethral incision of the prostate (TUIP): Effective for prostates <30g 2
   • Laser procedures (less bleeding, shorter catheterization)
   • Minimally invasive procedures (electrovaporization, transurethral microwave therapy)
   • Prostatic artery embolization: Outpatient procedure with lower risk of sexual side effects 5

Common Side Effects of Treatment

Alpha-blockers:

• Dizziness, headache, postural hypotension
• Less impact on sexual function compared to 5-ARIs

5-ARIs (Finasteride):

• Sexual dysfunction (decreased libido: 6.4% year 1,2.6% years 2-4)
• Erectile dysfunction (impotence: 8.1% year 1,5.1% years 2-4)
• Decreased ejaculate volume (3.7% year 1.5% years 2-4)
• Gynecomastia and breast tenderness 3

Surgical Treatments:

• Retrograde ejaculation (very common)
• Erectile dysfunction
• Urinary incontinence (1% with TURP)
• Bleeding requiring transfusion

Treatment Algorithm

1. Mild Symptoms (IPSS <8): Watchful waiting with lifestyle modifications
2. Moderate Symptoms (IPSS 8-19):
   • Small prostate (<30cc): Alpha-blocker monotherapy
   • Large prostate (>30cc): 5-ARI or combination therapy
3. Severe Symptoms (IPSS >19) or Complications:
   • Consider surgical intervention, particularly if:
     • Failed medical therapy
     • Recurrent UTIs
     • Bladder stones
     • Renal insufficiency
     • Acute urinary retention

Follow-up and Monitoring

• Evaluate patients 4-12 weeks after initiating treatment
• Assessment should include IPSS score, post-void residual (PVR), and uroflowmetry
• Monitor for progression of BPH, particularly in men over 70 years old who have increased risk of acute urinary retention

Important Caveats

• Medical therapies are not as effective as surgical treatments but provide adequate symptomatic relief with fewer adverse events
• 5-ARIs should not be tried in patients with prostate volume <40ml as they are less effective 2
• Combination therapy has more side effects but better outcomes for symptom progression
• Untreated BPH increases risk of complications including acute urinary retention