What are the treatment options for benign prostatic hyperplasia (BPH)?

Treatment Options for Benign Prostatic Hyperplasia (BPH)

The treatment of benign prostatic hyperplasia should follow a stepwise approach, beginning with watchful waiting for mild symptoms and progressing to medical therapy and surgical interventions for more bothersome symptoms or complications. 1, 2

Initial Assessment and Management

• Watchful waiting is the preferred management strategy for patients with mild symptoms (AUA Symptom Score <7) or those with moderate to severe symptoms that are not bothersome 1, 2
• During watchful waiting, patients should be monitored yearly with repeat evaluations 2
• Simple lifestyle modifications can reduce symptom distress:
  • Decreasing fluid intake at bedtime 1, 2
  • Reducing caffeine and alcohol consumption 1, 2
• Prostate volume assessment (via DRE or PSA) helps predict natural history and response to therapy 1, 2

Medical Therapy Options

Alpha-Adrenergic Blockers

• Alpha-blockers are first-line medical therapy for BPH, providing rapid symptom relief within 3-5 days 3
• They work by inhibiting alpha1-adrenergic-mediated contraction of prostatic smooth muscle 2
• Recommended options include:
  • Alfuzosin - selective with minimal blood pressure effects 2, 3
  • Doxazosin - effective but requires dose titration 2, 3
  • Tamsulosin - selective for alpha-1A receptors with lower risk of orthostatic hypotension 2, 3
  • Terazosin - effective but may affect blood pressure 2, 3
• Alpha-blockers produce on average a 4-6 point improvement in AUA Symptom Index 2
• Common side effects include dizziness, headache, asthenia, and ejaculatory dysfunction 4

5-Alpha Reductase Inhibitors

• Finasteride is indicated for symptomatic BPH in men with an enlarged prostate to:
  • Improve symptoms
  • Reduce the risk of acute urinary retention
  • Reduce the risk of surgery including TURP 4
• Most effective in men with prostate volumes >40 ml 5
• Requires 6-12 months for maximum effect and prostate shrinkage 5
• Side effects include sexual dysfunction (decreased libido, ejaculation disorders, impotence) 4

Combination Therapy

• Finasteride administered with doxazosin is indicated to reduce the risk of symptomatic progression of BPH 4
• Combination therapy may have more adverse effects, including asthenia and postural hypotension 4
• The incidence of abnormal ejaculation in patients receiving combination therapy is comparable to the sum of the incidences for the two monotherapies 4

Surgical Interventions

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, 2
• Indicated for patients with moderate-to-severe LUTS who have failed medical therapy 2
• Complications include sexual dysfunction, bladder neck contracture, need for blood transfusion, UTI, and hematuria 2

Minimally Invasive Options

• Transurethral Microwave Thermotherapy (TUMT) is an effective minimally invasive option 1, 2
• Transurethral Needle Ablation (TUNA) appears more effective than medical therapy but less effective than TURP 2, 6
• Laser therapies (HoLEP, PVP, thulium) are increasingly used, especially for patients on anticoagulation 7, 8
• Prostatic stents should be considered only in high-risk patients, especially those with urinary retention 2

Treatment Selection Algorithm

1. For mild symptoms (AUA score <7) or non-bothersome symptoms:

   • Watchful waiting with annual follow-up 1, 2

2. For moderate to severe bothersome symptoms (AUA score ≥8):

   • First line: Alpha-blockers (tamsulosin, alfuzosin, doxazosin, or terazosin) 2, 3
   • For enlarged prostates (>40ml): Consider 5-alpha reductase inhibitor (finasteride) alone or in combination with alpha-blocker 4, 5

3. For patients failing medical therapy or with complications:

   • Standard option: TURP (gold standard surgical intervention) 1, 2
   • For high-risk surgical patients: Consider minimally invasive options (TUMT, TUNA, laser therapies) 2, 7
   • For very large prostates: Open prostatectomy may be necessary 8

Important Considerations and Pitfalls

• Alpha-blockers provide rapid symptom relief but do not alter disease progression 3
• 5-alpha reductase inhibitors take 6-12 months for full effect but can prevent disease progression 5
• Patients on alpha-blockers should be monitored for orthostatic hypotension, especially with first dose 4
• Combination therapy is more effective than monotherapy but has higher rates of adverse effects 4
• The choice of surgical technique should consider prostate size, comorbidities (especially anticoagulation), and surgeon's experience 8
• Despite newer technologies, open prostatectomy and monopolar TURP remain the most commonly utilized surgical procedures 8