How to diagnose and manage Benign Prostatic Hyperplasia (BPH)?

Assessment and Management of Benign Prostatic Hyperplasia (BPH)

Diagnostic Evaluation

The diagnosis of BPH requires a systematic approach including medical history, symptom assessment using the AUA Symptom Index/IPSS, physical examination with digital rectal examination, urinalysis, and selective PSA testing. 1

Required Initial Evaluation

• Medical History: Obtain detailed history of urinary symptoms (storage and voiding symptoms), previous surgeries, medical conditions, medications, and family history of prostate disease 1, 2
• Symptom Assessment: Use the AUA Symptom Index/IPSS to quantify symptom severity (mild: 0-7, moderate: 8-19, severe: 20-35) 3, 1
• Physical Examination: Digital rectal examination (DRE) is mandatory to assess prostate size, consistency, and to exclude locally advanced prostate cancer 3, 1
• Urinalysis: Perform dipstick testing or microscopic examination to screen for hematuria and urinary tract infection 3, 1
• PSA Testing: Should be offered to patients with at least a 10-year life expectancy for whom knowledge of prostate cancer would change management, or when PSA measurement may influence voiding symptom management 3, 1

Optional Diagnostic Tests

• Urine Flow Rate: Measurement of maximum urinary flow rate (Qmax) is optional but recommended before invasive therapy 3, 1
• Post-void Residual Urine (PVR): Helps assess bladder emptying and predict both natural history and treatment response 3, 2
• Pressure-Flow Studies: Optional before invasive therapy, particularly for men with flow rates >10 mL/sec when surgery is being considered, or in those with neurological conditions affecting bladder function 3, 1
• Urethrocystoscopy: Appropriate for men with history of hematuria, urethral stricture, bladder cancer, or prior lower urinary tract surgery 3, 1
• Prostate Ultrasound: May be appropriate when minimally invasive or surgical interventions are chosen, but not routinely necessary for watchful waiting or medical therapy 3, 1

Not Recommended Tests

• Serum Creatinine: Routine measurement is not indicated in initial evaluation as baseline renal insufficiency is no more common in men with BPH than in the general population 3, 1
• Upper Urinary Tract Imaging: Not recommended unless specific indications exist such as hematuria, UTI, renal insufficiency, or history of urolithiasis 1

Management Based on Symptom Severity

Mild Symptoms (AUA Score 0-7)

• Watchful Waiting: Appropriate for asymptomatic patients or those with mild symptoms that don't affect quality of life 4, 5

Moderate Symptoms (AUA Score 8-19)

• Medical Therapy: First-line treatment for moderate symptoms 5
  • Alpha-blockers (e.g., tamsulosin): Provide rapid symptom relief; recommended starting dose is 0.4 mg once daily, approximately 30 minutes after the same meal each day 6, 4
  • 5-alpha-reductase inhibitors (e.g., finasteride): For patients with enlarged prostates (>40 mL); reduces prostate volume by approximately 18% over 4 years and improves symptoms 7, 4
  • Combination therapy: Alpha-blocker plus finasteride is indicated to reduce the risk of symptomatic progression of BPH 7, 4

Severe Symptoms (AUA Score 20-35) or Treatment Failures

• Surgical Intervention: Consider when symptoms are severe or when complications develop 7, 5
  • Indicated for patients with acute urinary retention, renal insufficiency due to BPH, recurrent UTIs, bladder stones, or persistent gross hematuria 5
  • Transurethral resection of the prostate (TURP) remains the gold standard surgical treatment 4
  • Transurethral incision of the prostate (TUIP) is effective for prostates <30g 4

Clinical Pearls and Pitfalls

Common Pitfalls

• Overlooking other causes of LUTS: Symptoms may be due to conditions other than BPH, such as urinary tract infection, bladder cancer, neurological disorders, or diabetes 1, 8
• PSA interpretation: Approximately 25% of men with BPH have PSA >4 ng/mL, which can lead to unnecessary concern about prostate cancer 3, 1
• Delayed assessment of treatment efficacy: Finasteride requires at least 6 months before effectiveness can be assessed and 12 months for maximum prostate shrinkage 7, 4

Important Considerations

• Finasteride effectiveness: Only effective in men with enlarged prostates (>40 mL); should not be tried in patients with smaller prostates 7, 4
• Alpha-blocker selection: Tamsulosin has fewer blood pressure effects compared to non-selective alpha-blockers, making it preferable in normotensive patients 6, 4
• Treatment goals: The primary aim of BPH treatment is to improve quality of life by reducing bothersome symptoms and preventing complications such as acute urinary retention or the need for surgery 7