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

Treatment of Benign Prostatic Hyperplasia

For men with mild BPH symptoms, watchful waiting with lifestyle modifications is the preferred initial approach, while those with moderate-to-severe symptoms should start alpha-blocker therapy, adding a 5-alpha reductase inhibitor if the prostate is >30cc. 1, 2

Initial Management Strategy

Watchful Waiting

• Watchful waiting is the preferred management for patients with mild symptoms and is appropriate even for moderate-to-severe symptoms if no complications exist (renal insufficiency, urinary retention, recurrent infections). 3, 2
• Implement lifestyle modifications: decrease fluid intake at bedtime, reduce caffeine and alcohol consumption. 2
• Monitor patients yearly with repeat International Prostate Symptom Score (IPSS) assessments. 1, 2

Medical Therapy

First-Line: Alpha-Blockers

• Alpha-blockers (alfuzosin, doxazosin, tamsulosin, terazosin) are appropriate first-line medical therapy for symptomatic BPH. 3, 1
• These agents produce 4-6 point improvement in symptom scores, which patients perceive as meaningful, with onset of action within 3-5 days. 2, 4
• Tamsulosin has lower risk of orthostatic hypotension but higher risk of ejaculatory dysfunction compared to non-selective alpha-blockers. 2, 4
• Non-selective alpha-blockers (doxazosin, terazosin) are preferable in hypertensive patients with BPH. 5

5-Alpha Reductase Inhibitors (5-ARIs)

• Add finasteride or dutasteride for patients with prostate size >30cc to reduce disease progression risk. 1, 6
• Finasteride is FDA-approved to improve symptoms, reduce risk of acute urinary retention, and reduce need for surgery including TURP. 6
• 5-ARIs require 6 months to assess effectiveness and 12 months for maximum benefit. 5
• These agents reduce the need for future BPH-related surgery and risk of urinary retention. 4

Combination Therapy

• Combination therapy with alpha-blocker plus 5-ARI is indicated for patients with larger prostates and moderate-to-severe symptoms. 1
• Combination therapy (finasteride plus doxazosin) reduces risk of symptomatic progression more effectively than monotherapy. 6
• Common pitfall: Combination therapy increases adverse effects including asthenia, postural hypotension, peripheral edema, dizziness, decreased libido, and abnormal ejaculation compared to monotherapy. 2, 6

Alternative Medical Options

• PDE-5 inhibitors (tadalafil 5 mg daily) can be considered for BPH symptoms, particularly in patients with concurrent erectile dysfunction. 4, 7
• Muscarinic receptor antagonists are viable for patients with predominantly bladder storage symptoms and small prostates. 7

Surgical Intervention

Absolute Indications for Surgery

Surgery is recommended for patients with: 3

• Refractory urinary retention after failed catheter removal attempt
• Renal insufficiency clearly due to BPH
• Recurrent urinary tract infections due to BPH
• Recurrent gross hematuria due to BPH
• Bladder stones due to BPH
• Symptoms refractory to medical therapy 1

Surgical Options

• TURP remains the benchmark surgical treatment with the most published evidence of long-term efficacy. 3, 2
• Transurethral incision of the prostate is effective with minimal adverse effects for prostates <30g. 5
• Minimally invasive options include transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA), which are less effective than TURP but have fewer complications. 2, 8
• Newer modalities include HoLEP, Greenlight laser, and prostatic urethral lift. 9

Important Surgical Considerations

• TURP complications include sexual dysfunction, bladder neck contracture, need for blood transfusion, UTI, and hematuria. 2
• Balloon dilation is not recommended as a treatment option due to significant failure rates over time. 3

Special Clinical Scenarios

Urinary Retention

• Concomitant administration of an alpha-blocker (tamsulosin or alfuzosin) is an option prior to attempted catheter removal. 3
• Voiding trial is more likely successful if retention was precipitated by temporary factors (anesthesia, sympathomimetic medications). 3
• For patients who are not surgical candidates, treatment with intermittent catheterization, indwelling catheter, or stent is recommended. 3

Prostatic Stents

• Prostatic stents should be considered only in high-risk patients, especially those with urinary retention, due to significant complications including encrustation, infection, and chronic pain. 2

Follow-Up Protocol

• Evaluate patients 4-12 weeks after initiating treatment to assess response using IPSS questionnaire. 1
• Further evaluation may include post-void residual (PVR) and uroflowmetry. 1
• Monitor patients on alpha-blockers for orthostatic hypotension, especially with first dose. 2

Key Clinical Pitfalls

• Do not use 5-ARIs in patients with prostate volume <40ml as efficacy is dependent on prostate size. 5
• Avoid alpha-blockers in patients with prior history of alpha-blocker side effects or unstable medical comorbidities (orthostatic hypotension, cerebrovascular disease). 3
• Be aware that finasteride increases incidence of high-grade (Gleason 8-10) prostate cancer (1.8% vs 1.0% placebo) based on the PCPT trial. 6