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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

The most effective treatment approach for BPH should be based on symptom severity, with watchful waiting for mild symptoms, medical therapy for moderate symptoms, and surgical interventions for severe symptoms or those who have failed other therapies. 1, 2

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, 2
• During watchful waiting, patients should be monitored yearly with repeat evaluations of symptoms 1
• Simple lifestyle modifications can reduce symptom distress, including decreasing fluid intake at bedtime and reducing caffeine and alcohol consumption 1, 2

Medical Therapy Options

Alpha-Adrenergic Blockers

• Alpha-blockers work by inhibiting alpha1-adrenergic-mediated contraction of prostatic smooth muscle, providing rapid symptom relief within weeks 2, 3
• Recommended options include alfuzosin, doxazosin, tamsulosin, and terazosin 1, 2
• These agents produce on average a 4-6 point improvement in AUA Symptom Index, which patients perceive as meaningful 2, 4
• Key differences between alpha-blockers: tamsulosin has a lower risk of orthostatic hypotension but a higher risk of ejaculatory dysfunction 2, 4

5-Alpha-Reductase Inhibitors

• Finasteride is indicated for symptomatic BPH in men with an enlarged prostate to improve symptoms, reduce acute urinary retention risk, and reduce need for surgery 5
• Efficacy is dependent on prostate size; not recommended for prostates <40ml 6
• Requires 6 months before effectiveness can be assessed and 12 months for maximum prostate shrinkage 6
• Common side effects include sexual dysfunction (decreased libido, impotence, ejaculation disorders) 5

Combination Therapy

• Finasteride administered with alpha-blocker doxazosin is indicated to reduce the risk of symptomatic progression of BPH 5
• Combination therapy may have more adverse effects, including asthenia and postural hypotension 2
• The MTOPS study showed combination therapy was more effective than either monotherapy, but with increased side effects 5

Surgical Interventions

• Surgical intervention is appropriate for patients with moderate-to-severe LUTS who have failed medical therapy 2
• TURP remains the benchmark for surgical therapies due to published evidence of efficacy from randomized clinical trials with long-term follow-up 1, 2, 7
• Complications of TURP include sexual dysfunction, bladder neck contracture, need for blood transfusion, UTI, and hematuria 2
• Transurethral incision of the prostate (TUIP) is an effective therapy with minimal adverse effects in patients with prostates not larger than 30g 6

Minimally Invasive Options

• Transurethral Microwave Thermotherapy (TUMT) is a minimally invasive option with efficacy between medical therapy and TURP 1, 2
• Transurethral Needle Ablation (TUNA) appears to be more effective than medical therapy but less effective than TURP 2
• Prostatic artery embolization (PAE) is a newer outpatient intervention performed by interventional radiologists that preserves ejaculatory function 8
• These alternatives are less costly per treatment episode, require less time to produce positive outcomes, and have less associated morbidity 1

Treatment Selection Algorithm

1. Assess symptom severity using validated tools (AUA Symptom Index/IPSS)

   • Mild symptoms (IPSS <8): Watchful waiting 1
   • Moderate symptoms (IPSS 8-19): Consider medical therapy 1, 2
   • Severe symptoms (IPSS ≥20): Consider surgical options 1, 2

2. For medical therapy selection:

   • For rapid symptom relief: Alpha-blockers 3
   • For enlarged prostates (>40ml): 5-alpha-reductase inhibitors or combination therapy 5, 6
   • For patients with hypertension: Consider non-selective alpha-blockers like doxazosin 6

3. For surgical candidates:

   • Prostate <30g: Consider TUIP 6
   • Larger prostates: TURP remains the gold standard 1, 7
   • High-risk surgical patients: Consider minimally invasive options 1, 8

Important Considerations

• Prostate volume assessment helps predict natural history and response to therapy 1, 2
• Patients on alpha-blockers should be monitored for orthostatic hypotension, especially with first dose 2, 4
• 5-alpha-reductase inhibitors may increase the risk of high-grade prostate cancer and require monitoring 5
• The choice between treatment options should consider the patient's prostate size, comorbidities, and surgeon's experience 2