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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

For patients with mild symptoms, watchful waiting with lifestyle modifications is the preferred initial approach, while those with bothersome moderate-to-severe symptoms should receive alpha-blockers as first-line medical therapy, with surgical intervention (TURP) reserved for medical therapy failures or complications. 1, 2, 3

Initial Assessment and Watchful Waiting

Watchful waiting is appropriate for:

• Patients with mild symptoms who are not bothered by their condition 1
• Selected patients with moderate-to-severe symptoms who have not developed complications 1
• During this period, monitor patients yearly with repeat evaluations 1

Lifestyle modifications that reduce symptom burden include:

• Decreasing fluid intake at bedtime 1, 2
• Reducing caffeine and alcohol consumption 1, 2

First-Line Medical Therapy: Alpha-Blockers

Alpha-blockers are the first-line pharmacologic treatment for bothersome BPH symptoms because they provide rapid symptom relief within 2-4 weeks by relaxing prostatic smooth muscle 2, 4, 3. These agents work regardless of prostate size 2.

Recommended alpha-blocker options include:

• Alfuzosin 1, 4
• Doxazosin 1
• Terazosin 1
• Tamsulosin 4, 3

Expected outcomes: Alpha-blockers produce an average 4-6 point improvement in AUA Symptom Index that patients perceive as meaningful 1, 2.

Key clinical differences:

• Tamsulosin has a lower risk of orthostatic hypotension but a higher risk of ejaculatory dysfunction 1, 2
• Nonselective alpha-blockers (doxazosin, terazosin) are preferable in hypertensive patients with BPH 5
• Monitor all patients on alpha-blockers for orthostatic hypotension, especially with the first dose 1

5-Alpha Reductase Inhibitors (5-ARIs)

5-ARIs should be used in patients with enlarged prostates (>40 mL) to reduce prostate volume and prevent disease progression 2, 5. These agents require 6 months to assess effectiveness and at least 12 months for maximum benefit 5.

Available agents:

• Finasteride 5 mg daily 6, 5, 4
• Dutasteride 4

FDA-approved indications for finasteride include:

• Improving symptoms in men with enlarged prostates 6
• Reducing risk of acute urinary retention 6
• Reducing risk of need for surgery including TURP 6

Additional benefits:

• 5-ARIs may reduce prostatic bleeding 2
• Serum PSA serves as a proxy for prostate volume and predicts response to 5-ARI therapy 2

Important caveat: Finasteride should not be used in patients with prostate volume <40 mL as efficacy is dependent on prostate size 5.

Combination Therapy

Combination therapy with finasteride and doxazosin is indicated to reduce the risk of symptomatic BPH progression (confirmed ≥4 point increase in AUA symptom score) 2, 6. Dutasteride combined with tamsulosin is also indicated for symptomatic BPH in men with enlarged prostates 2.

Critical warning about adverse effects: Combination therapy increases adverse effects including asthenia and postural hypotension compared to monotherapy 1, 2, 6. In the MTOPS trial, the incidence of abnormal ejaculation in combination therapy was comparable to the sum of incidences from both monotherapies 6.

Surgical Intervention: TURP as the Gold Standard

TURP remains the benchmark surgical therapy for BPH due to robust long-term efficacy data from randomized clinical trials 1, 2, 5.

Absolute indications for surgery include:

• Refractory urinary retention 2
• Renal insufficiency due to BPH 2
• Recurrent urinary tract infections 2
• Recurrent gross hematuria 2
• Bladder stones due to BPH 2
• Failure of medical therapy in patients with moderate-to-severe LUTS 1, 2

TURP complications to discuss with patients:

• Sexual dysfunction (mainly ejaculatory dysfunction) 1, 7
• Bladder neck contracture 1
• Need for blood transfusion 1
• UTI 1
• Hematuria 1
• Clinically significant adverse events occur in 20% of patients 5

Minimally Invasive Therapies

For patients who prefer less invasive options or are high-risk surgical candidates:

• Transurethral Microwave Thermotherapy (TUMT) is a minimally invasive option 1
• Transurethral Needle Ablation (TUNA) appears more effective than medical therapy but less effective than TURP 1
• 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 1

Important limitation: The Panel concluded that additional data are required before interstitial laser coagulation and water-induced thermotherapy can be considered as recommended treatment options, despite FDA approval 8.

Emerging and Investigational Therapies

High-intensity focused ultrasound and absolute ethanol injection are investigational and should not be offered outside clinical trials 8.

Balloon dilation is not an acceptable treatment option based on inadequate long-term efficacy data 8.

Therapies NOT Recommended

Phytotherapeutic agents and dietary supplements (saw palmetto, pygeum, cernilton, beta-sitosterols) cannot be recommended for BPH treatment 8, 3. Acupuncture is also not recommended 3.

Newer Option: PDE-5 Inhibitors

Tadalafil 5 mg once daily has been shown to improve BPH-related symptoms and is approved for treating patients with BPH 4.

Referral Criteria to Urology

Refer to a urologist for:

• Rising PSA, especially while on 5-ARI 4
• Failure of urinary symptom control despite maximal medical therapy 4
• Suspicion of prostate cancer 4
• Hematuria 4
• Recurrent urinary infections 4
• Urinary retention 4
• Renal failure 4

Critical Clinical Pearls

• Patient perception of symptom severity and impact on quality of life should be the primary consideration in choosing therapy, not measurable physiological factors 8
• Prostate volume assessment helps predict natural history and response to therapy 1
• Surgical decisions should consider prostate size, comorbidities, and surgeon's experience 1
• BPH-associated mortality is rare in the United States, and serious complications are uncommon 8