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

Initial Treatment Options for Benign Prostatic Hyperplasia (BPH)

Alpha blockers are the first-line treatment option for patients with bothersome, moderate to severe lower urinary tract symptoms (LUTS) due to BPH, with 5-alpha reductase inhibitors (5-ARIs) recommended for patients with prostatic enlargement. 1

Medical Therapy Options

Alpha Blockers

• Alpha blockers (alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin) are equally effective in improving symptoms, producing a 4-7 point improvement in the International Prostate Symptom Score (IPSS) compared to 2-4 points with placebo 1
• Selection of specific alpha blocker should be based on:
  • Patient age and comorbidities
  • Different adverse event profiles (e.g., ejaculatory dysfunction, blood pressure changes) 1
• Alpha blockers work rapidly and are effective regardless of prostate size, symptom severity, or degree of obstruction 2
• Common side effects include orthostatic hypotension, dizziness, tiredness, ejaculatory problems, and nasal congestion 1
• Tamsulosin appears to have a lower probability of orthostatic hypotension but higher probability of ejaculatory dysfunction compared to other alpha blockers 1
• Patients planning cataract surgery should be informed about the risk of Intraoperative Floppy Iris Syndrome (IFIS) associated with alpha blockers 1

5-Alpha Reductase Inhibitors (5-ARIs)

• 5-ARIs (finasteride, dutasteride) are recommended for patients with:
  • Prostate volume >30cc on imaging
  • PSA >1.5ng/mL
  • Palpable prostate enlargement on digital rectal exam 1
• 5-ARIs reduce prostate volume, improve symptoms, and increase urinary flow rates 3
• They require at least 6 months to assess effectiveness and 12 months for maximum prostate shrinkage 3
• 5-ARIs alone or in combination with alpha blockers can prevent disease progression and reduce risks of urinary retention and future prostate-related surgery 1
• Patients should be informed about potential sexual side effects before starting 5-ARIs 1
• Finasteride is FDA-approved for treatment of symptomatic BPH to improve symptoms, reduce risk of acute urinary retention, and reduce need for surgery 4

Combination Therapy

• Combination of alpha blockers and 5-ARIs is recommended for patients at risk of BPH progression 1
• The Medical Therapy of Prostatic Symptoms (MTOPS) and Combination of Avodart and Tamsulosin (CombAT) studies showed significant reductions in clinical progression with combination therapy compared to monotherapy 1
• Finasteride in combination with doxazosin is specifically indicated to reduce the risk of symptomatic progression of BPH 4
• Combination of alpha blockers with anticholinergics may be beneficial in selected patients with storage-predominant symptoms, but should be initiated with alpha blockers alone first, with anticholinergics added if needed 1
• The combination of low-dose daily tadalafil with alpha blockers is not recommended as it offers no advantages in symptom improvement over either agent alone 1

Watchful Waiting

• Watchful waiting is the preferred management strategy for patients with mild symptoms 1
• It's also appropriate for patients with moderate to severe symptoms who have not developed complications of BPH 1
• Simple measures like decreasing fluid intake at bedtime and reducing caffeine and alcohol intake can help reduce symptom distress 1
• Patients on watchful waiting should be reexamined yearly 1

Management of Acute Urinary Retention (AUR)

• Physicians should prescribe an oral alpha blocker prior to a voiding trial for patients with AUR related to BPH 1
• Patients should complete at least three days of alpha blocker therapy before attempting trial without catheter (TWOC) 1
• Nontitratable alpha blockers (tamsulosin or alfuzosin) may be preferable prior to catheter removal 1
• Patients who pass a successful TWOC should be informed they remain at increased risk for recurrent urinary retention 1
• Surgery is recommended for patients with refractory retention who have failed at least one attempt at catheter removal 1

Surgical Indications

• Surgery is recommended for patients with:
  • Refractory urinary retention
  • Renal insufficiency due to BPH
  • Recurrent UTIs due to BPH
  • Recurrent gross hematuria due to BPH
  • Bladder stones due to BPH that are refractory to other therapies 1
• The presence of a bladder diverticulum is not an absolute indication for surgery unless associated with recurrent UTI or progressive bladder dysfunction 1

Monitoring and Follow-up

• Patients should be assessed using IPSS and/or Global Subjective Assessment questions at follow-up visits 1
• For patients on anticholinergics, post-void residual (PVR) should be obtained pre-treatment and monitored at follow-up 1
• When medical management fails to address symptoms or intolerable side effects occur, urologic referral for additional workup and/or alternate treatments is recommended 1

Important Considerations

• Alpha blockers work more rapidly than 5-ARIs and are considered first-line therapy for most patients with symptomatic BPH 2
• 5-ARIs are more effective in patients with larger prostates (>30-40cc) 3
• Patients with planned cataract surgery should discuss alpha blocker use with their ophthalmologists 1
• Balloon dilation is not recommended as a treatment option for patients with BPH symptoms 1