What are the treatment options for benign prostatic hyperplasia (BPH), specifically comparing Transurethral Resection of the Prostate (TURP) and finasteride (5-alpha-reductase inhibitor)?

Discussing TURP vs. Finasteride Treatment Options for BPH

For patients with benign prostatic hyperplasia (BPH), finasteride is most appropriate for those with enlarged prostates (>30cc), while TURP is more effective for immediate symptom relief and should be considered for patients with severe symptoms, acute urinary retention, or those who have failed medical therapy. 1, 2

Finasteride Treatment Option

Mechanism and Efficacy

• Finasteride inhibits 5-alpha-reductase type II isoenzyme, reducing dihydrotestosterone (DHT) in the prostate by approximately 70%, leading to a 15-25% reduction in prostate size within 6 months 1
• Patients experience an average 3-point improvement in symptom scores, which is generally perceived as a meaningful change 1, 2
• Finasteride provides greater benefit in men with larger prostates (>30cc) and/or higher PSA values 1, 2
• Long-term studies show symptom improvements maintained for 6-10 years 1

Benefits of Finasteride

• Reduces the risk of acute urinary retention by 57% compared to placebo 2
• Reduces the risk of BPH-related surgery, including TURP, by 55% 2
• Non-invasive option with fewer immediate risks than surgery 3
• Can be taken as a daily pill (5mg) with minimal monitoring required 2, 4

Limitations and Side Effects

• Slower onset of action (3-6 months for noticeable improvement) compared to TURP or alpha blockers 1, 4
• Common side effects include decreased libido (6.4% in first year) and ejaculatory dysfunction (3.7% in first year) 1
• Side effects typically become less common after the first year of therapy 1
• Reduces PSA by approximately 50%, which must be considered when screening for prostate cancer 1, 2

TURP Treatment Option

Procedure and Efficacy

• TURP involves surgical removal of the inner portion of the prostate through the urethra 5
• Provides immediate and significant improvement in urinary symptoms and flow rate 5, 3
• Most effective therapy for BPH with substantial prostatic enlargement 5, 3
• Results are typically long-lasting, though some patients may require retreatment years later 3

Benefits of TURP

• Provides rapid relief of obstructive symptoms 3
• Definitive treatment that addresses the underlying anatomical obstruction 5
• Particularly effective for patients with acute urinary retention or severe symptoms 5
• Eliminates the need for daily medication 3

Limitations and Risks

• Associated with clinically significant adverse events in approximately 20% of patients 3
• Requires hospitalization and recovery period 3
• Potential complications include bleeding, infection, retrograde ejaculation, urinary incontinence, and erectile dysfunction 3
• Not all patients are good surgical candidates due to comorbidities 5

Combination Therapy Considerations

• Combination therapy with finasteride and an alpha-blocker provides greater symptom relief than either medication alone 5, 2
• In the MTOPS trial, combination therapy reduced the risk of BPH progression by 67% compared to placebo 2
• Consider combination therapy as an intermediate step before proceeding to TURP 5, 2

Patient Selection Algorithm

Consider Finasteride When:

• Patient has moderate symptoms with documented prostate enlargement (>30cc) 1, 2
• Patient prefers non-surgical approach 3
• Patient can tolerate waiting 3-6 months for symptom improvement 1, 4
• Patient has no contraindications to finasteride 2

Consider TURP When:

• Patient has severe symptoms significantly affecting quality of life 5
• Patient has acute urinary retention or recurrent urinary tract infections 5, 2
• Patient has failed medical therapy or prefers immediate relief 5, 3
• Patient is a good surgical candidate without prohibitive comorbidities 5

Common Pitfalls to Avoid

• Using finasteride in patients without prostatic enlargement is ineffective 1, 6
• Failing to adjust PSA interpretation in patients on finasteride (double the PSA value after 1 year of therapy) 1
• Not allowing adequate time (at least 6 months) to assess finasteride's effectiveness 1, 4
• Not discussing all potential side effects of both treatments, including sexual side effects 1, 3
• Proceeding directly to TURP without trying medical therapy in appropriate candidates 5, 3