What are the treatment options for benign prostatic hyperplasia (BPH)?

Treatment Indications for Benign Prostatic Hyperplasia

Treatment for BPH is indicated when patients have bothersome moderate to severe lower urinary tract symptoms (AUA Symptom Score ≥8), or when complications such as urinary retention, recurrent infection, or renal insufficiency develop. 1

Symptom-Based Treatment Algorithm

Mild Symptoms or Non-Bothersome Symptoms

• Watchful waiting is the standard management for patients with mild symptoms (AUA Symptom Score <7) or those with any severity of symptoms that do not interfere with daily activities 1
• These patients should not receive active treatment because the risks of medical therapy outweigh potential benefits when symptoms don't significantly impact quality of life 1
• Annual monitoring with repeat symptom assessment is appropriate 1
• Simple lifestyle modifications include reducing evening fluid intake and limiting caffeine and alcohol 1

Bothersome Moderate to Severe Symptoms (AUA Score ≥8)

When symptoms are bothersome enough that patients seek treatment, all therapeutic options should be discussed, including their benefits and harms 1

Medical Therapy Indications

First-line medical treatment options include: 1

• Alpha-adrenergic blockers (alfuzosin, doxazosin, tamsulosin, or terazosin) are appropriate for any patient with bothersome LUTS secondary to BPH 1, 2

  • These agents provide symptom improvement within 2-4 weeks 3
  • All four agents have equal clinical effectiveness with slight differences in adverse-event profiles 1
  • Expected improvement: 4-6 point reduction in AUA Symptom Score 1
  • No additional testing required before initiating therapy 1

• 5-alpha-reductase inhibitors (finasteride or dutasteride) are indicated for symptomatic BPH, particularly in men with enlarged prostates 4, 5

  • Finasteride improves symptoms, reduces risk of acute urinary retention, and reduces need for surgery including TURP 4
  • Dutasteride similarly improves symptoms, reduces AUR risk, and reduces need for BPH-related surgery 5
  • Most effective in patients with prostate volume >40 ml 6
  • Requires 6-12 months for maximum effect 6, 3

• Combination therapy (alpha-blocker plus 5-alpha-reductase inhibitor) is indicated to reduce risk of symptomatic BPH progression 1, 4

  • Best-tested combination is doxazosin plus finasteride 1
  • Dutasteride combined with tamsulosin is also FDA-approved 5

Minimally Invasive Therapy Indications

Consider for patients who: 1

• Prefer to avoid surgery or no longer respond to medication 7
• Have moderate to severe bothersome symptoms but want less invasive options than surgery 1
• Are high-risk surgical candidates 6

Options include transurethral microwave thermotherapy (TUMT), transurethral needle ablation (TUNA), and various laser procedures 1

Surgical Therapy Indications

Surgery is indicated for: 1

• Absolute indications (complications of BPH):

  • Renal insufficiency due to BPH 1
  • Recurrent or persistent urinary retention 1, 4
  • Recurrent urinary tract infections 1
  • Bladder calculi 8
  • Recurrent gross hematuria 1

• Relative indications:

  • Bothersome moderate to severe symptoms that failed medical therapy 9, 7
  • Patient preference for definitive treatment 1
  • Patients most bothered by urinary symptoms at baseline achieve best surgical outcomes 8

Surgical options include: 1

• Transurethral resection of the prostate (TURP) - remains the benchmark therapy 1
• Transurethral incision of the prostate (TUIP) - effective for prostates <30g 6
• Laser procedures (holmium laser resection/enucleation, laser vaporization) 1
• Open prostatectomy for very large glands 1

Key Clinical Pitfalls

• Do not treat non-bothersome symptoms regardless of severity score, as treatment risks outweigh benefits 1
• Prazosin and phenoxybenzamine are not recommended for BPH treatment due to insufficient data or safety concerns 1
• Neither finasteride nor dutasteride are approved for prostate cancer prevention 4, 5
• Patients planning cataract surgery should inform their ophthalmologist about alpha-blocker use due to intraoperative floppy iris syndrome risk 2
• Surgery produces better outcomes than watchful waiting for reducing treatment failure rates (relative risk 0.48), but watchful waiting remains safe for less bothered patients 8