What is the treatment for Grade 1 benign prostatic hyperplasia (BPH)?

Treatment for Grade 1 Benign Prostatic Hyperplasia (BPH)

Watchful waiting is the preferred management strategy for patients with mild symptoms (Grade 1 BPH) and is also appropriate for patients with moderate to severe symptoms who are not bothered by them. 1

Initial Management Approach

• Watchful waiting involves monitoring the patient without active intervention for BPH 1
• Patients with mild symptoms (AUA Symptom Score <7) should be managed using watchful waiting 1
• Patients with moderate or severe symptoms (AUA Symptom Score >8) who are not bothered by their symptoms should also be managed with watchful waiting 1
• During watchful waiting, patients are typically reexamined yearly, repeating the initial evaluation 1

Lifestyle Modifications During Watchful Waiting

• Symptom distress may be reduced with simple measures such as:
  • Decreasing fluid intake at bedtime 1
  • Decreasing caffeine and alcohol intake generally 1
  • Implementing other behavioral modifications to reduce symptom impact 1

When to Consider Medical Therapy

• Medical therapy may be considered if:
  • Symptoms progress and become bothersome 1, 2
  • The patient has demonstrable prostatic enlargement 1, 3
  • The patient wishes to reduce risk of disease progression 1

Medical Treatment Options

Alpha-Adrenergic Blockers

• Alpha blockers are first-line drugs for symptomatic BPH when medical therapy is indicated 2, 4
• Options include alfuzosin, doxazosin, tamsulosin, and terazosin 1
• These medications work by inhibiting alpha1-adrenergic-mediated contraction of prostatic smooth muscle 1
• Alpha blockers usually take effect quickly (within 3-5 days) 2
• They provide an average 4-6 point improvement in the AUA Symptom Index 1
• Common side effects include orthostatic hypotension, dizziness, tiredness, ejaculatory problems, and nasal congestion 1

5-Alpha-Reductase Inhibitors

• Finasteride and dutasteride are appropriate for patients with LUTS associated with demonstrable prostatic enlargement 1
• These medications are ineffective in patients who do not have enlarged prostates 1, 3
• Finasteride reduces prostate size by 15-25% within 6 months 5
• Patients experience an average 3-point improvement in symptom scores 1, 3
• Side effects are primarily sexually related (decreased libido, ejaculatory dysfunction) 1
• Finasteride reduces the risk of acute urinary retention and the need for BPH-related surgery 1, 6

Common Pitfalls to Avoid

• Initiating medical therapy for patients with mild symptoms who are not bothered by them 1
• Using 5-alpha-reductase inhibitors in patients without prostatic enlargement 1, 3
• Not allowing adequate time (at least 6 months) to assess finasteride's effectiveness 7
• Failing to adjust PSA interpretation in patients on finasteride (PSA decreases by approximately 50%) 3
• Proceeding directly to surgical options without trying appropriate medical therapy first 7

When to Consider Referral to Urology

• Development of complications such as renal insufficiency, urinary retention, or recurrent infections 1
• Failure of symptom control despite maximal medical therapy 2
• Suspicion of prostate cancer 2
• Hematuria or bladder stones 2

Algorithm for Management

1. Assess symptom severity using AUA Symptom Index/IPSS
2. For mild symptoms (AUA <7): Implement watchful waiting with lifestyle modifications 1
3. For moderate-severe symptoms that are not bothersome: Continue watchful waiting 1
4. For bothersome moderate-severe symptoms with enlarged prostate: Consider medical therapy 1
   • Alpha blockers for rapid symptom relief 1, 2
   • 5-alpha-reductase inhibitors for long-term management in enlarged prostates 1, 3
5. For symptoms with complications (retention, recurrent UTIs, bladder stones): Consider surgical referral 1