What are the recommended treatments for Benign Prostatic Hyperplasia (BPH)?

Recommended Treatments for Benign Prostatic Hyperplasia (BPH)

The management of BPH should follow a stepwise approach, starting with watchful waiting for mild symptoms, progressing to medical therapy with alpha-blockers and/or 5-alpha reductase inhibitors for moderate symptoms, and surgical intervention for severe symptoms or complications.

Initial Management: Watchful Waiting

• Watchful waiting is the preferred management strategy for patients with mild symptoms and should be considered for those with moderate to severe symptoms who have not developed complications 1
• During watchful waiting, patients should be monitored yearly with repeat evaluations 1
• Simple lifestyle modifications can reduce symptom distress:
  • Decreasing fluid intake at bedtime 1
  • Reducing caffeine and alcohol consumption 1

Medical Therapy Options

Alpha-Adrenergic Blockers (First-Line Medical Therapy)

• Alpha-blockers work by inhibiting alpha1-adrenergic-mediated contraction of prostatic smooth muscle, relieving bladder outlet obstruction 1
• Recommended alpha-blockers include:
  • Tamsulosin (0.4 mg once daily, can be increased to 0.8 mg if needed) 2
  • Alfuzosin 1
  • Doxazosin 1
  • Terazosin 1
• These agents produce on average a 4-6 point improvement in AUA Symptom Index, which patients perceive as meaningful 1
• Alpha-blockers typically take effect quickly (within 3-5 days) 3
• Key differences between alpha-blockers:
  • Tamsulosin has lower risk of orthostatic hypotension but higher risk of ejaculatory dysfunction 1
  • Tamsulosin is more selective for alpha-1A receptors and doesn't require dosage titration 4
  • Non-selective alpha-blockers (doxazosin, terazosin) may be preferable in patients with concurrent hypertension 4

5-Alpha Reductase Inhibitors

• Finasteride is indicated for:
  • Treatment of symptomatic BPH in men with enlarged prostate 5
  • Reducing risk of acute urinary retention 5
  • Reducing need for surgery including TURP 5
• Most effective in men with prostate volume >40 ml 4
• Requires 6 months before effectiveness can be assessed and 12 months for maximum prostate shrinkage 4
• Common adverse effects include sexual dysfunction:
  • Impotence (8.1% in year 1) 5
  • Decreased libido (6.4% in year 1) 5
  • Decreased ejaculate volume (3.7% in year 1) 5

Combination Therapy

• Finasteride in combination with doxazosin is indicated to reduce risk of symptomatic progression of BPH 5
• Combination therapy may have more adverse effects than monotherapy, including:
  • Asthenia
  • Postural hypotension
  • Dizziness
  • Sexual dysfunction 5

Surgical Interventions

• Surgical intervention is appropriate for:
  • Patients with moderate-to-severe LUTS who have failed medical therapy
  • Patients with acute urinary retention or other BPH-related complications
  • Patients who prefer the most effective therapy initially 1

Transurethral Resection of the Prostate (TURP)

• TURP remains the benchmark for surgical therapies due to published evidence of efficacy from randomized clinical trials with long-term follow-up 1
• Involves surgical removal of the prostate's inner portion via an endoscopic approach through the urethra 1
• Complications include:
  • Sexual dysfunction
  • Irritative voiding symptoms
  • Bladder neck contracture
  • Need for blood transfusion
  • UTI
  • Hematuria 1

Minimally Invasive Options

• Transurethral Microwave Thermotherapy (TUMT) 1
• Transurethral Needle Ablation (TUNA) - appears to be more effective than medical therapy but less effective than TURP 1
• Laser therapies (HoLEP, PVP) - can be used in patients on anticoagulation 6

Prostatic Stents

• Should be considered only in high-risk patients, especially those with urinary retention 1
• Associated with significant complications such as encrustation, infection, and chronic pain 1

Treatment Selection Algorithm

1. Assess symptom severity using AUA Symptom Index/IPSS
2. For mild symptoms: Watchful waiting with lifestyle modifications
3. For moderate symptoms without complications:
   • Start with alpha-blocker (tamsulosin, alfuzosin, doxazosin, or terazosin)
   • Add 5-alpha reductase inhibitor (finasteride) if prostate is enlarged (>40 ml)
4. For severe symptoms or complications (renal insufficiency, urinary retention, recurrent infection):
   • Consider surgical intervention, with TURP as the standard option
   • Consider minimally invasive alternatives based on patient factors and surgeon experience

Important Considerations and Pitfalls

• Prostate volume assessment (via DRE or PSA) helps predict natural history and response to therapy 1
• Alpha-blockers provide faster symptom relief but do not alter disease progression 4
• 5-alpha reductase inhibitors work more slowly but can reduce prostate size and prevent complications 3
• Patients on alpha-blockers should be monitored for orthostatic hypotension, especially with first dose 1
• When using finasteride, counsel patients about the delayed onset of action and potential sexual side effects 4
• Surgical decisions should consider the patient's prostate size, comorbidities, and surgeon's experience 1