What are the guidelines for non-pharmacological management of Benign Prostatic Hyperplasia (BPH)?

Non-Pharmacological Management Guidelines for Benign Prostatic Hyperplasia (BPH)

Watchful waiting is the preferred management strategy for patients with mild symptoms of BPH and should be considered for those with moderate to severe symptoms who have not developed complications. 1, 2

Initial Evaluation

• The initial evaluation of patients with bothersome LUTS possibly attributed to BPH should include a medical history, physical examination (including digital rectal examination), International Prostate Symptom Score (IPSS), and urinalysis 1
• Patients should be counseled on all available intervention options, including behavioral/lifestyle modifications, medical therapy, and procedural options 1
• Follow-up evaluation should occur 4-12 weeks after initiating treatment to assess response to therapy, including reassessment with the IPSS 1

Watchful Waiting

• Watchful waiting involves monitoring the patient without active intervention 1
• This approach is most appropriate for patients with mild symptoms (low IPSS scores) 1, 2
• During watchful waiting, patients should be monitored yearly with repeat evaluations 2
• The level of symptom distress that individual patients can tolerate is highly variable, making watchful waiting a viable option even for some patients with higher symptom scores 1

Behavioral and Lifestyle Modifications

• Simple lifestyle modifications can significantly reduce symptom distress and should be the first-line approach 2:
  • Decreasing fluid intake at bedtime 2
  • Reducing caffeine and alcohol consumption 2
  • Avoiding medications that can worsen urinary symptoms (e.g., decongestants, antihistamines) 1
  • Bladder training and timed voiding 2
  • Avoiding constipation 2

Monitoring and Follow-up

• Patients on watchful waiting should be re-examined yearly, repeating the initial evaluation 1
• Prostate volume assessment by digital rectal examination and/or serum PSA helps predict the natural history of symptoms, flow rate, and risk for acute urinary retention 1
• Patients should be advised about their individual risk based on these assessments 1

When to Consider Medical or Surgical Intervention

• Patients with bothersome LUTS/BPH who elect initial management and do not have symptom improvement should undergo further evaluation and consideration of change in management 1
• Medical therapy should be considered for patients with moderate symptoms who are bothered enough to request treatment 1, 2
• Surgical intervention is appropriate for patients with moderate-to-severe LUTS who have failed medical therapy 2
• Patients with complications of BPH (renal insufficiency, urinary retention, recurrent infection) should be considered for more aggressive treatment options 1

Minimally Invasive Options

• Several minimally invasive options exist for patients who prefer to avoid surgery or who no longer respond favorably to medication 3:
  • Transurethral Microwave Thermotherapy (TUMT) 2
  • Transurethral Needle Ablation (TUNA) 2
  • Temporary implantable devices (e.g., iTind) may be an option for select patients who wish to preserve ejaculatory function 4

Caveats and Pitfalls

• The impact of LUTS on quality of life is highly variable and not directly related to measurable physiological factors 1
• Patient perception of symptom severity and the degree to which it interferes with lifestyle should be the primary consideration in choosing therapy 1
• Prostatic stents should only be considered in high-risk patients, especially those with urinary retention, due to significant complications such as encrustation, infection, and chronic pain 2
• Avoid assuming that all LUTS in older men are due to BPH; other conditions such as overactive bladder may coexist or be the primary cause 1

By following these non-pharmacological management guidelines, clinicians can help patients with BPH manage their symptoms effectively while minimizing the need for medication or invasive procedures when appropriate.