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

Treatment Options for Benign Prostatic Hyperplasia (BPH)

Alpha blockers (tamsulosin, alfuzosin, doxazosin, terazosin, or silodosin) are the first-line pharmacological treatment for BPH, providing rapid symptom relief within 3-5 days with a 4-6 point improvement in symptom scores that patients perceive as meaningful. 1, 2

Medical Management

Alpha Blockers (First-Line)

• All five alpha blockers—alfuzosin, doxazosin, silodosin, tamsulosin, and terazosin—are equally effective for treating bothersome moderate to severe lower urinary tract symptoms, producing 4-7 point improvements in International Prostate Symptom Score (IPSS) compared to 2-4 points with placebo. 1, 2

• Tamsulosin and alfuzosin are non-titratable and can be started immediately without dose adjustment, while doxazosin and terazosin require gradual dose titration to minimize first-dose hypotensive effects. 2, 3

• Tamsulosin has significantly less effect on blood pressure and lower risk of orthostatic hypotension compared to other alpha blockers, making it the preferred choice for elderly patients and those with cardiovascular concerns. 1, 2

• However, tamsulosin carries a higher probability of ejaculatory dysfunction compared to other alpha blockers. 1, 2

• Common side effects across all alpha blockers include orthostatic hypotension, dizziness, tiredness, ejaculatory problems, and nasal congestion. 1, 2

• Patients planning cataract surgery should delay alpha blocker initiation until after the procedure due to risk of intraoperative floppy iris syndrome (IFIS). 1

• Doxazosin monotherapy was associated with higher incidence of congestive heart failure in men with hypertension and cardiac risk factors, so alpha blockers should not be assumed to adequately manage concomitant hypertension—these patients require separate hypertension management. 1, 2

5-Alpha Reductase Inhibitors (5-ARIs)

• 5-ARIs (finasteride or dutasteride) should be used for symptom improvement only in patients with prostatic enlargement, defined as prostate volume >30cc on imaging, PSA >1.5 ng/mL, or palpable enlargement on digital rectal exam. 1

• 5-ARIs are ineffective in patients without prostatic enlargement and should not be used in this population. 1, 2

• Finasteride produces an average 3-point improvement in symptom scores, which is less effective than alpha blockers but still meaningful to patients. 1, 2

• 5-ARIs alone or combined with alpha blockers are strongly recommended to prevent disease progression and reduce risks of urinary retention and future prostate-related surgery. 1, 4

• Finasteride requires 6 months to assess effectiveness and at least 12 months to achieve maximum prostate shrinkage, making it slower-acting than alpha blockers. 1

• Sexual side effects—decreased libido, ejaculatory dysfunction, and erectile dysfunction—are the primary adverse events and must be discussed before initiating therapy. 1, 4

• Patients must be informed about the increased incidence of high-grade (Gleason 8-10) prostate cancer observed in the PCPT trial (1.8% with finasteride vs 1.4% with placebo). 4

Combination Therapy

• Combination therapy with finasteride and doxazosin is FDA-approved to reduce risk of symptomatic BPH progression (defined as ≥4 point increase in AUA symptom score). 4

• In the MTOPS study, combination therapy showed higher rates of asthenia, postural hypotension, peripheral edema, dizziness, decreased libido, rhinitis, abnormal ejaculation, impotence, and abnormal sexual function compared to monotherapy. 4

• The incidence of abnormal ejaculation with combination therapy was comparable to the sum of incidences from both monotherapies. 4

Surgical Management

Transurethral Resection of the Prostate (TURP)

• TURP remains the gold standard surgical treatment for BPH, particularly for patients with refractory urinary retention, renal insufficiency, recurrent UTIs, recurrent gross hematuria, or bladder stones clearly due to BPH and refractory to medical therapy. 2, 5

• TURP achieves a 91% response rate (≥30% reduction in IPSS) at 12 months, significantly superior to all other treatment modalities. 6

• Complications include sexual dysfunction, bladder neck contracture, need for blood transfusion, UTI, and hematuria. 5

Prostatic Urethral Lift (PUL)

• Prostatic urethral lift is recommended for patients with prostate volume <80g and no obstructing middle lobe, particularly when preservation of sexual function is a priority, but with clear understanding that symptom improvement and flow rates are significantly inferior to TURP. 6

• PUL achieves a 73% response rate at 12 months compared to 91% with TURP, representing a measurable functional disadvantage. 6

• Maximum flow rate (Qmax) is significantly lower with PUL compared to TURP at all time points. 6

• PUL demonstrates superior ejaculatory function preservation compared to TURP, making it suitable for men prioritizing sexual function. 6

• Preoperative cystoscopy is mandatory to verify absence of middle lobe obstruction, and prostate volume must be measured by transrectal ultrasound or MRI. 6

• The American Urological Association rates PUL as a Moderate Recommendation with Evidence Level Grade C due to limited long-term data and inferior efficacy. 6

Alternative Surgical Options

• For patients with prostate volume ≥80g or obstructing middle lobe, holmium laser enucleation (HoLEP), thulium laser enucleation (ThuLEP), or TURP should be considered instead of PUL. 6

• Patients prioritizing maximal symptom relief over sexual function should be offered TURP as first-line surgical treatment. 6

Management of Acute Urinary Retention

• Initial treatment for acute urinary retention is immediate catheterization followed by alpha blocker administration (preferably tamsulosin or alfuzosin) for at least 3 days before attempting catheter removal. 2, 5

• Alpha blockers significantly improve trial without catheter success rates: alfuzosin 60% vs 39% placebo; tamsulosin 47% vs 29% placebo. 2

• If catheter removal fails after alpha blocker treatment, surgery is recommended. 2, 5

Treatment Algorithm

1. For all symptomatic BPH patients: Start with alpha blocker (tamsulosin preferred for elderly/cardiovascular patients; other alpha blockers acceptable for younger patients or those with hypertension requiring dual benefit). 1, 2

2. For patients with prostatic enlargement (volume >30cc, PSA >1.5, or palpable enlargement): Add 5-ARI to prevent progression and reduce surgical risk, or use as monotherapy if patient prefers slower onset with disease-modifying benefit. 1, 2

3. For acute urinary retention: Catheterize immediately, start alpha blocker, attempt catheter removal after 3+ days; if unsuccessful, proceed to surgery. 2, 5

4. For refractory symptoms despite maximal medical therapy, or complications (retention, renal insufficiency, recurrent UTI, hematuria, bladder stones): Refer for surgical intervention. 2, 5

5. For surgical candidates prioritizing sexual function with prostate <80g and no middle lobe: Consider PUL with clear counseling about inferior efficacy. 6

6. For surgical candidates prioritizing maximal symptom relief, or those with prostate ≥80g or middle lobe obstruction: Offer TURP or laser enucleation. 6, 5

Critical Pitfalls to Avoid

• Never use 5-ARIs in patients without prostatic enlargement—they are completely ineffective in this population. 1, 2

• Do not assume alpha blockers adequately manage concomitant hypertension, especially with doxazosin given its association with increased heart failure risk. 1, 2

• Balloon dilation is not recommended due to inadequate results and significant failure rates over time. 2

• Always delay alpha blocker initiation in patients with planned cataract surgery to avoid IFIS complications. 1

• Do not offer PUL to patients with prostate volume ≥80g or obstructing middle lobe—these are absolute contraindications. 6