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

Treatment for Benign Prostatic Hyperplasia

For patients with bothersome moderate to severe BPH symptoms (AUA Symptom Score >8), alpha-blockers are the first-line medical therapy due to their superior symptom relief (4-6 point improvement in AUA Symptom Index) compared to 5-alpha-reductase inhibitors (3-point improvement), with faster onset of action. 1

Initial Assessment and Stratification

Watchful waiting is appropriate for:

• Patients with mild symptoms 2
• Patients with moderate to severe symptoms who are not bothered enough to pursue active treatment 1
• During watchful waiting, monitor yearly with repeat evaluations and implement lifestyle modifications (reduce evening fluid intake, limit caffeine and alcohol) 2

Medical therapy should be offered when:

• AUA Symptom Score >8 with bothersome symptoms 1
• Patients must be counseled on benefits and harms of all treatment options before initiating therapy 1

Medical Therapy Algorithm

Alpha-Blocker Monotherapy (First-Line)

Recommended agents include: alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin 1

All alpha-blockers are similarly effective (4-6 point IPSS improvement), but differ in adverse effect profiles: 1

• Tamsulosin and silodosin: Lower risk of orthostatic hypotension but higher risk of ejaculatory dysfunction 1
• Doxazosin and terazosin: Require dose titration; higher risk of orthostatic hypotension and dizziness 1
• Alfuzosin: Intermediate profile 1

Critical caveat: In men with hypertension and cardiac risk factors, doxazosin monotherapy was associated with higher incidence of congestive heart failure; alpha-blockers should not be assumed to constitute optimal hypertension management 1

For patients planning cataract surgery: Inform about intraoperative floppy iris syndrome (IFIS) risk and consider delaying alpha-blocker initiation until after surgery 1

5-Alpha-Reductase Inhibitor (5-ARI) Monotherapy

Use 5-ARI monotherapy when prostate enlargement is documented: 1

• Prostate volume >30cc on imaging, OR
• PSA >1.5 ng/mL, OR
• Palpable prostate enlargement on DRE

Available agents: finasteride 5 mg daily or dutasteride (similar efficacy and safety profiles) 1, 3

Key characteristics of 5-ARIs: 1, 4

• Less effective than alpha-blockers for symptom improvement (3-point vs 4-6 point IPSS improvement)
• Requires 6 months to assess effectiveness, 12 months for maximum benefit 5
• Major advantage: Reduces risk of acute urinary retention and need for BPH-related surgery 1
• Reduces prostate volume by approximately 20-25% 1, 6
• Ineffective in patients without prostatic enlargement 1

Adverse effects to discuss: 1, 3

• Sexual dysfunction (decreased libido, erectile dysfunction, ejaculatory dysfunction) - most common in first year, then decreases 1, 3
• Decreases PSA by approximately 50% (does not mask prostate cancer detection) 1, 3
• FDA warning: Higher incidence of Gleason 8-10 prostate cancer observed in PCPT trial (1.8% vs 1.0% placebo) 3

Combination Therapy (Alpha-Blocker + 5-ARI)

Combination therapy is indicated to: 1, 3

• Reduce risk of symptomatic BPH progression (≥4 point increase in AUA score)
• Further reduce risk of urinary retention and need for surgery beyond either monotherapy 1

Best-studied combination: doxazosin plus finasteride 1

Adverse effects are additive: 1, 2, 3

• Higher incidence of asthenia, postural hypotension, peripheral edema, dizziness, and sexual dysfunction compared to monotherapy 3
• Ejaculatory dysfunction in combination therapy is comparable to sum of both monotherapies 3

Clinical strategy: Consider combination therapy in patients with large prostates (>30-40cc) and moderate-to-severe symptoms who need both immediate symptom relief (from alpha-blocker) and long-term disease modification (from 5-ARI) 4, 7

Minimally Invasive Therapies

Consider when medical therapy fails or is not tolerated: 1, 2

Options include: 1, 2

• Transurethral microwave thermotherapy (TUMT)
• Transurethral needle ablation (TUNA) - more effective than medical therapy but less effective than TURP 2
• Efficacy lies between TURP and medical therapy 2
• Can be performed as outpatient procedures with shorter hospitalization 5

Prostatic stents: Only for high-risk patients, especially those with urinary retention, due to significant complications (encrustation, infection, chronic pain) 1, 2

Surgical Therapy

TURP remains the benchmark surgical therapy with strongest long-term efficacy data from randomized trials 2, 5

Indications for surgical referral: 1, 2

• Moderate-to-severe LUTS refractory to medical therapy
• Intolerable drug-related side effects
• Complications of BPH (recurrent urinary retention, recurrent UTIs, bladder stones, renal insufficiency)

Surgical options: 1

• Transurethral resection of the prostate (TURP) - gold standard
• Transurethral incision of the prostate (TUIP) - effective for prostates <30g 5
• Transurethral electrovaporization
• Laser procedures (holmium laser enucleation, laser vaporization)
• Open prostatectomy - for very large glands

TURP complications to discuss: 2

• Sexual dysfunction, bladder neck contracture, need for blood transfusion (20% experience clinically significant adverse events), UTI, hematuria 2, 5

Follow-Up Strategy

Monitor treatment response using: 1

• IPSS scores and Global Subjective Assessment (GSA)
• If patient reports improvement matching IPSS improvement: continue therapy 1
• If patient reports neutral/worsening response despite stable/improved IPSS: reassess and discuss alternative treatments 1
• If medical management fails: refer to urology for additional workup (urodynamics, cystoscopy, prostate volume assessment) and alternate treatments 1