What are the treatment options for benign prostatic hyperplasia (BPH)?

Treatment Options for Benign Prostatic Hyperplasia (BPH)

For patients with bothersome moderate-to-severe BPH symptoms, initiate an alpha blocker (alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin) as first-line therapy, and add a 5-alpha reductase inhibitor (finasteride or dutasteride) if the prostate is enlarged (>30cc volume, PSA >1.5 ng/mL, or palpable enlargement on DRE). 1, 2

Initial Management Strategy

Watchful Waiting

• Preferred for patients with mild symptoms who are not bothered by their condition 1, 2
• Appropriate even for moderate-to-severe symptoms if the patient has not developed complications (renal insufficiency, urinary retention, recurrent infections) 1
• Implement lifestyle modifications: reduce evening fluid intake, decrease caffeine and alcohol consumption 1
• Re-evaluate yearly with repeat symptom assessment 1

Medical Therapy

Alpha-Adrenergic Blockers (First-Line)

• Offer alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin for bothersome moderate-to-severe LUTS 1
• All alpha blockers are relatively equally effective, improving IPSS by 4-7 points compared to placebo (2-4 points) 1
• Onset of action is rapid: 3-5 days 3
• Selection should be based on adverse event profiles: ejaculatory dysfunction (particularly with silodosin and tamsulosin) versus blood pressure changes (with non-selective agents like doxazosin and terazosin) 1
• Critical caveat: Patients planning cataract surgery should be informed of intraoperative floppy iris syndrome (IFIS) risk and should delay alpha blocker initiation until after the procedure 1

5-Alpha Reductase Inhibitors (5-ARIs)

• Use finasteride or dutasteride for symptom improvement only when prostate enlargement is documented: volume >30cc on imaging, PSA >1.5 ng/mL, or palpable enlargement on DRE 1, 4
• Primary benefit: prevention of disease progression, reducing risk of acute urinary retention and need for future surgery 1, 4
• Requires 6 months to assess effectiveness and 12 months for maximum benefit 5
• Counsel patients about sexual side effects (decreased libido, erectile dysfunction, ejaculatory dysfunction) and potential for gynecomastia 4
• Important safety consideration: The PCPT trial showed higher incidence of high-grade (Gleason 8-10) prostate cancer in finasteride-treated patients (1.8% vs 1.4% placebo), though this remains controversial 4

Combination Therapy

• Indicated for patients with larger prostates (>30cc) and moderate-to-severe symptoms 2
• Combination of alpha blocker plus 5-ARI reduces risk of symptomatic BPH progression (confirmed ≥4 point increase in AUA symptom score) 4
• Expect additive adverse effects: The combination produces higher rates of asthenia, postural hypotension, peripheral edema, dizziness, decreased libido, and abnormal ejaculation compared to monotherapy 4

Phosphodiesterase-5 Inhibitors

• Tadalafil 5 mg daily is approved for BPH treatment and improves symptoms 3
• Consider particularly in patients with concomitant erectile dysfunction 3

Surgical Interventions

Indications for Surgery

Absolute indications requiring urologic referral 2, 6:

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

Surgical Options

Gold Standard:

• Transurethral resection of the prostate (TURP) remains the benchmark therapy with highest efficacy 1, 6
• Associated with 20% rate of clinically significant adverse events including sexual dysfunction, bladder neck contracture, bleeding requiring transfusion, UTI 6, 5

Alternative Surgical Procedures:

• Open prostatectomy: For very large prostates, most effective for complete tissue removal 6
• Holmium laser enucleation (HoLEP): Complete tissue removal with potentially fewer bleeding complications 6
• Transurethral incision of the prostate (TUIP): Effective for prostates <30g with minimal adverse effects 5
• Laser vaporization and electrovaporization: Outpatient options with shorter hospitalization 6, 5

Minimally Invasive Options:

• Transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA): More effective than medical therapy but less effective than TURP 6
• Efficacy lies between TURP and medical therapy 5

Not Recommended:

• Balloon dilation: Inadequate results and high failure rates 6
• Prostatic artery embolization (PAE): Should only be offered in clinical trials 6

Follow-Up Protocol

• Evaluate patients 4-12 weeks after initiating treatment 2
• Reassess using IPSS questionnaire, consider post-void residual and uroflowmetry 2
• If medical management fails or intolerable side effects occur, refer to urology for additional workup (urodynamics, cystoscopy, prostate volume assessment) and alternate treatments 1
• If no significant improvement after 6 months of 5-ARI or 2-3 months of alpha blocker, consider urology consultation 7

Special Populations

• Hypertensive patients: Non-selective alpha blockers (doxazosin, terazosin) provide dual benefit for blood pressure control 5
• Patients with erectile dysfunction: Consider tadalafil or combination with PDE-5 inhibitor 3
• High surgical risk patients: Minimally invasive procedures can be performed safely 5