What are the treatment guidelines for benign prostatic hypertrophy (BPH)?

Treatment Guidelines for Benign Prostatic Hyperplasia (BPH)

Alpha-blockers are the first-line medical therapy for BPH, while surgical intervention is recommended for patients with severe symptoms, complications, or those who fail medical therapy. 1

Diagnostic Assessment

• Essential evaluations:
  • Medical history and International Prostate Symptom Score (IPSS)
  • Digital rectal examination (DRE) to assess prostate size and morphology
  • Urinalysis to rule out infection, hematuria, and other conditions 1
  • Post-void residual (PVR) measurement and uroflowmetry for objective assessment 1
  • Prostate volume assessment via ultrasound when considering 5-alpha reductase inhibitor therapy 1

Treatment Algorithm

1. Watchful Waiting

• Appropriate for:
  • Patients with mild symptoms 2, 1
  • Patients with moderate-to-severe symptoms who are not significantly bothered 2
• Management includes:
  • Yearly re-examination
  • Lifestyle modifications: decreasing fluid intake at bedtime, reducing caffeine and alcohol consumption 2, 1

2. Medical Therapy

Alpha-Blockers

• First-line therapy for symptomatic BPH 1
• Options: alfuzosin, doxazosin, tamsulosin, terazosin 2, 1
• Mechanism: Relaxation of prostatic smooth muscle and relief of bladder outlet obstruction 1
• Dosing: For tamsulosin, 0.4 mg once daily taken 30 minutes after the same meal each day; can be increased to 0.8 mg if inadequate response after 2-4 weeks 3
• Advantages:
  • Rapid symptom relief
  • Improves both voiding and storage symptoms 4
• Side effects:
  • Orthostatic hypotension, dizziness, tiredness (less with tamsulosin) 1
  • Ejaculatory dysfunction (more common with tamsulosin) 1

5-Alpha Reductase Inhibitors (5-ARIs)

• Appropriate for: Patients with prostate size >30cc or PSA >1.5ng/mL 1
• Options: Finasteride
• Indications: Treatment of symptomatic BPH, reducing risk of acute urinary retention and need for surgery 5
• Mechanism: Reduces prostate volume by 20-30% 1
• Limitations:
  • Slower onset of action (6-12 months) 6
  • Not approved for prostate cancer prevention 5

Combination Therapy

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

Other Medical Options

• PDE5 inhibitors: Consider tadalafil 5mg daily for patients with concurrent erectile dysfunction and BPH 1
• Anticholinergics or beta-3 agonists: For persistent storage symptoms despite alpha-blocker therapy 1

3. Surgical Therapy

• Indications:

  • Refractory symptoms despite medical therapy
  • Acute urinary retention
  • Recurrent UTIs
  • Bladder stones
  • Renal insufficiency due to BPH 1
  • Patient preference for definitive treatment 2

• Transurethral Resection of the Prostate (TURP):

  • Remains the benchmark surgical therapy 2, 1
  • More effective than watchful waiting in reducing treatment failure and improving symptoms 7
  • Complications include bleeding, sexual dysfunction, bladder neck contracture, UTI 2

• Minimally Invasive Options:

  • Transurethral microwave thermotherapy (TUMT)
  • Transurethral needle ablation (TUNA)
  • Appropriate for selected patients based on prostate anatomy 2, 6

Follow-up and Monitoring

• Evaluate response to treatment after 4-12 weeks of initiating therapy 1
• Follow-up visits:
  • 4 weeks for alpha-blockers, anticholinergics, beta-3 agonists, and PDE5 inhibitors
  • 3-6 months for 5-ARIs 1
• Assessment should include IPSS score, medication side effects, and optionally PVR and uroflowmetry 1

Important Clinical Considerations

• Inform patients on alpha-blockers about the risk of intraoperative floppy iris syndrome if cataract surgery is planned 1
• Discuss potential sexual side effects with patients starting 5-ARIs 1
• Surgery is most beneficial for patients who are most bothered by urinary symptoms 7
• Treatment choice should be based on symptom severity, prostate size, and patient preference 8