What are the treatment options for an enlarged prostate (Benign Prostatic Hyperplasia)?

Treatment Options for Benign Prostatic Hyperplasia (BPH)

Alpha blockers should be offered as the first-line treatment option for patients with benign prostatic hyperplasia presenting with bothersome lower urinary tract symptoms (LUTS), providing rapid symptom relief by relaxing smooth muscle in the prostate and bladder neck. 1

Initial Treatment Approach

• Alpha blockers improve symptoms by 4-7 points on the International Prostate Symptom Score (IPSS) compared to 2-4 points with placebo, with clinical effects typically appearing within 2-4 weeks 1
• Tamsulosin produces on average a 4-6 point improvement in the AUA Symptom Index, which patients generally perceive as a meaningful change 2
• Alpha blockers (tamsulosin, alfuzosin, doxazosin, and terazosin) have similar clinical effectiveness in relieving symptoms, but differ in side effect profiles 2
• Tamsulosin appears to have a lower probability of orthostatic hypotension but a higher probability of ejaculatory dysfunction compared to other alpha blockers 2

Selection of Alpha Blocker

• The choice of alpha blocker should be based on patient age, comorbidities, and potential side effect profiles 1
• Tamsulosin and alfuzosin have better tolerability profiles than doxazosin or terazosin 3
• Doxazosin should be used cautiously in patients with hypertension and cardiac risk factors due to increased risk of congestive heart failure 1
• Patients undergoing cataract surgery should inform their ophthalmologist about tamsulosin use due to the risk of intraoperative floppy iris syndrome 2

5-Alpha Reductase Inhibitors (5-ARIs)

• Finasteride is indicated for the treatment of symptomatic BPH in men with an enlarged prostate to improve symptoms, reduce the risk of acute urinary retention, and reduce the need for surgery 4
• 5-ARIs are most effective in patients with demonstrable prostatic enlargement (prostate volume >30cc) 5
• Finasteride is ineffective in patients who do not have enlarged prostates 5
• Finasteride reduces prostate size by 15-25% after 6 months of treatment 1
• Finasteride decreases serum PSA levels by approximately 50%, which should be considered when screening for prostate cancer 5

Combination Therapy

• Finasteride administered in combination with the alpha-blocker doxazosin is indicated to reduce the risk of symptomatic progression of BPH 4
• Combination therapy with an alpha blocker and finasteride is more effective than finasteride alone for immediate symptom relief 5
• The MTOPS study showed that combination therapy significantly reduced the risk of symptom score progression compared to finasteride alone or doxazosin alone 4

Surgical Options

• Surgery is recommended for patients with refractory urinary retention who have failed at least one attempt at catheter removal 6
• Surgery is also recommended for patients who have renal insufficiency clearly due to BPH and in those with recurrent UTIs, recurrent gross hematuria, or bladder stones clearly due to BPH and refractory to other therapies 6
• Transurethral resection of the prostate (TURP) or open prostatectomy are currently the most effective therapies for BPH, though TURP is associated with clinically significant adverse events in 20% of patients 7

Common Side Effects to Monitor

• Alpha blockers can cause orthostatic hypotension, dizziness, fatigue, ejaculatory problems, and nasal congestion 1
• Decreased libido is a common side effect of finasteride, occurring in 6.4% of patients in the first year and 2.6% in years 2-4 5
• Ejaculatory dysfunction is another side effect of finasteride, occurring in 3.7% of patients in the first year and 1.5% in years 2-4 5
• Alpha blockers, particularly silodosin and tamsulosin, can cause seminal vesicle enlargement and ejaculatory dysfunction 8

Important Clinical Considerations

• When screening for prostate cancer in men on finasteride, the measured PSA value should be doubled after 1 year of therapy to accurately assess disease progression 5
• Alpha blockers used for LUTS should not be assumed to adequately control hypertension; separate management may be required 1
• 5-ARIs should not be used as first-line therapy for BPH without evidence of significant prostate enlargement 1
• Finasteride has a slower onset of action compared to alpha blockers; patients should be counseled that symptom improvement may take several months 5

Follow-Up and Monitoring

• Patients should be evaluated 4-12 weeks after initiating treatment to assess response 1
• Follow-up should include IPSS assessment and may include post-void residual (PVR) measurement and uroflowmetry 1