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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

The treatment of BPH should follow a stepwise approach based on symptom severity, with options ranging from watchful waiting for mild symptoms to medical therapy with alpha blockers and 5-alpha reductase inhibitors for moderate symptoms, and surgery for severe symptoms or complications. 1

Initial Management

• Watchful waiting is the preferred management strategy for patients with mild symptoms and is appropriate for men with moderate to severe symptoms who have not yet developed complications of BPH 1
• Simple lifestyle modifications can help reduce symptom distress:
  • Decreasing fluid intake at bedtime
  • Reducing caffeine and alcohol consumption 1
• Patients under watchful waiting should be reexamined yearly with repeat of initial evaluation 1

Medical Therapy Options

Alpha Blockers

• Alpha blockers (alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin) are first-line medical therapy for patients with bothersome moderate to severe LUTS/BPH 1
• Alpha blockers work by inhibiting alpha1-adrenergic-mediated contraction of prostatic smooth muscle, relieving bladder outlet obstruction 1
• Benefits:
  • Rapid onset of action (within weeks) 2
  • Produce 4-6 point improvement in AUA Symptom Index 1
  • Effective regardless of prostate size 3
• Side effects include:
  • Orthostatic hypotension
  • Dizziness
  • Tiredness (asthenia)
  • Ejaculatory problems
  • Nasal congestion 1
• When selecting an alpha blocker, consider:
  • Tamsulosin has lower risk of orthostatic hypotension but higher risk of ejaculatory dysfunction 1
  • Non-titratable alpha blockers (tamsulosin or alfuzosin) may be preferable prior to catheter removal attempts in urinary retention 1
  • Patients planning cataract surgery should be informed of risks related to Intraoperative Floppy Iris Syndrome (IFIS) 1

5-Alpha Reductase Inhibitors (5-ARIs)

• 5-ARIs (finasteride, dutasteride) are appropriate for patients with LUTS/BPH with prostatic enlargement (prostate volume >30cc, PSA >1.5ng/mL, or palpable enlargement on DRE) 1
• Finasteride is indicated for:
  • Improving symptoms
  • Reducing risk of acute urinary retention
  • Reducing risk of BPH-related surgery 4
• Benefits:
  • Reduces prostate size
  • Increases peak urinary flow rate
  • Average 3-point improvement in AUA Symptom Index 1
  • May decrease probability of prostate bleeding 1
• Limitations:
  • Less effective than alpha blockers for symptom relief 1
  • Ineffective in patients without enlarged prostates 1
  • Requires 6-12 months for full effect 5
• Side effects are primarily sexual:
  • Decreased libido
  • Ejaculatory dysfunction
  • Erectile dysfunction 1

Combination Therapy

• Finasteride administered with alpha blocker doxazosin is indicated to reduce risk of symptomatic BPH progression 4
• Combination therapy may be more effective than either drug alone but has higher incidence of adverse effects 4

Surgical Management

• Surgery is recommended for patients with: 1
  • Refractory urinary retention who have failed at least one catheter removal attempt
  • Renal insufficiency clearly 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
• Transurethral resection of the prostate (TURP) remains the gold standard for surgical treatment 6
• For patients who are not surgical candidates, options include:
  • Intermittent catheterization
  • Indwelling catheter
  • Prostatic stent 1

Minimally Invasive Procedures

• Several minimally invasive treatments are available with efficacy between TURP and medical therapy 6
• Balloon dilation is not recommended as a treatment option for BPH 1
• Transurethral microwave thermotherapy (TUMT) and other minimally invasive treatments have insufficient outcomes data for patients with urinary retention 1

Treatment Algorithm Based on Symptom Severity and Complications

1. Mild symptoms without complications:

   • Watchful waiting with annual follow-up 1

2. Moderate to severe symptoms without complications:

   • First-line: Alpha blockers (alfuzosin, doxazosin, tamsulosin, terazosin) 1
   • For enlarged prostates: 5-ARIs or combination therapy 1, 4

3. BPH with complications (urinary retention, renal insufficiency, recurrent UTIs, hematuria, bladder stones):

   • Surgery (typically TURP) if patient is a suitable surgical candidate 1
   • For non-surgical candidates: catheterization or stent placement 1
   • Alpha blocker may be tried prior to catheter removal in urinary retention 1

Common Pitfalls and Caveats

• Alpha blockers should not be assumed to provide optimal management of concomitant hypertension; separate management may be required 1
• 5-ARIs should not be used in patients without prostatic enlargement as they are ineffective 1
• Bladder diverticulum alone is not an absolute indication for surgery unless associated with recurrent UTI or progressive bladder dysfunction 1
• When using doxazosin in patients with hypertension and cardiac risk factors, be aware of potential increased risk of congestive heart failure 1