What are the treatment options for Benign Prostatic Hyperplasia (BPH)?

Treatment Options for Benign Prostatic Hyperplasia (BPH)

Initial Assessment and Stratification

Treatment decisions for BPH depend primarily on symptom severity and bother level, not prostate size alone. 1

Watchful Waiting (No Active Treatment)

• Patients with mild symptoms (AUA Symptom Score <7) or those with moderate-to-severe symptoms who are not bothered by them should be managed with watchful waiting. 1
• Men whose symptoms do not interfere with daily activities should not receive active treatment, as the risks of medical therapy outweigh benefits in this population 1

Pharmacological Treatment Options

First-Line: Alpha Blockers

Alpha blockers are the first-line pharmacological treatment for BPH, providing rapid symptom relief within 2-4 weeks. 2, 3

• All four alpha blockers (tamsulosin, alfuzosin, doxazosin, terazosin) demonstrate similar clinical effectiveness with a 4-6 point improvement in AUA Symptom Index 2
• Tamsulosin is preferred for elderly patients and those with hypertension because it has less effect on blood pressure compared to other alpha blockers 2
• Non-titratable alpha blockers (tamsulosin, alfuzosin) can be started immediately without dose titration, while doxazosin and terazosin require gradual dose escalation to minimize first-dose hypotensive effects 2

Common side effects include:

• Orthostatic hypotension, dizziness, tiredness, nasal congestion 2
• Tamsulosin has lower probability of orthostatic hypotension but higher probability of ejaculatory dysfunction compared to other alpha blockers 2

Critical pitfall: In patients with hypertension, doxazosin monotherapy was associated with higher incidence of congestive heart failure than other antihypertensive agents—manage hypertension separately 2

Second-Line: 5-Alpha Reductase Inhibitors

5-alpha reductase inhibitors (finasteride, dutasteride) are appropriate only for patients with LUTS associated with demonstrable prostatic enlargement. 2

• Finasteride produces a 3-point improvement in AUA Symptom Index, but requires 6-12 months to achieve maximum effect 2, 4, 3
• These medications are completely ineffective in patients without enlarged prostates and should not be used in this population 2
• Finasteride is FDA-approved to improve symptoms, reduce risk of acute urinary retention, and reduce need for surgery including TURP 4

Side effects are primarily sexual:

• Decreased libido, ejaculatory dysfunction, erectile dysfunction 2, 4
• In the PCPT trial, finasteride was associated with higher incidence of high-grade (Gleason 8-10) prostate cancer (1.8% vs 1.0% placebo) 4

Combination Therapy

• Finasteride combined with doxazosin is FDA-approved to reduce risk of symptomatic BPH progression (≥4 point increase in AUA symptom score) 4
• Combination therapy in the MTOPS study showed additive adverse effects, particularly abnormal ejaculation (14.1% vs 7.2% finasteride alone vs 4.5% doxazosin alone) 4

Management of Acute Urinary Retention

The initial treatment for acute urinary retention is immediate catheterization followed by alpha blocker administration before attempting catheter removal. 2, 5

• Start a non-titratable alpha blocker (tamsulosin or alfuzosin) and continue for at least 3 days before attempting trial without catheter 5
• Alpha blockers significantly improve trial without catheter success rates: alfuzosin 60% vs 39% placebo; tamsulosin 47% vs 29% placebo 2, 5
• If catheter removal fails after alpha blocker treatment, surgery is recommended 2, 5

Surgical Treatment Options

Surgery is indicated for patients with:

• Refractory urinary retention after failed catheter removal trial 2, 6
• Renal insufficiency, recurrent UTIs, recurrent gross hematuria, or bladder stones clearly due to BPH and refractory to other therapies 2

Transurethral Resection of the Prostate (TURP)

TURP is the gold standard surgical treatment for BPH. 6, 7

• Most effective therapy for BPH, though associated with clinically significant adverse events in 20% of patients 7
• Complications include sexual dysfunction, bladder neck contracture, need for blood transfusion, UTI, and hematuria 6
• Requires general or spinal anesthesia and hospital stay 6

Alternative Surgical Options

• Transurethral incision of the prostate is effective with minimal adverse effects in patients with prostate ≤30g 7
• Minimally invasive procedures (electrovaporization, laser prostatectomy, transurethral needle ablation, transurethral microwave therapy) can be performed as outpatient procedures with shorter hospitalization 1, 7
• Efficacy of minimally invasive procedures lies between TURP and medical therapy 7

Critical pitfall: Balloon dilation is not recommended as a treatment option for BPH due to inadequate study results and significant failure rates 2, 6, 5

Treatment Algorithm Summary

1. Mild or non-bothersome symptoms: Watchful waiting 1
2. Moderate-to-severe bothersome symptoms: Start alpha blocker (tamsulosin preferred for elderly/hypertensive patients) 2
3. Large prostate with LUTS: Consider 5-alpha reductase inhibitor or combination therapy 2, 4
4. Acute urinary retention: Catheterize, start alpha blocker for ≥3 days, attempt catheter removal 5
5. Failed medical therapy or complications: Proceed to TURP 2, 6