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, alpha-blockers (alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin) should be offered as first-line medical therapy, providing rapid symptom relief within 3-5 days with a 4-7 point improvement in symptom scores. 1, 2

Initial Assessment and Stratification

Mild Symptoms (Grade 1 BPH):

• Watchful waiting is the preferred management strategy, involving active monitoring without pharmacological intervention 3
• Implement lifestyle modifications: decrease fluid intake at bedtime, reduce caffeine consumption, and limit alcohol intake 3
• Annual re-evaluation should be performed, repeating the initial assessment 3

Moderate to Severe Bothersome Symptoms:

• Medical therapy is indicated and should be initiated promptly 1, 3

First-Line Medical Therapy: Alpha-Blockers

All five alpha-blockers demonstrate similar clinical effectiveness with 4-7 point IPSS improvement compared to placebo (2-4 points), and patients perceive this level of improvement as meaningful 1, 2

Choice of alpha-blocker should be based on:

• Tamsulosin or alfuzosin (non-titratable agents): Can be initiated without dose titration, making them preferable for rapid symptom relief 1, 2

  • Tamsulosin has less effect on blood pressure, making it safer for elderly patients and those with hypertension 2, 4
  • However, tamsulosin has higher probability of ejaculatory dysfunction compared to other alpha-blockers 1, 2

• Doxazosin or terazosin (titratable agents): Require dose titration to minimize first-dose hypotensive effects 2

  • May be preferred in hypertensive patients with BPH, though doxazosin monotherapy was associated with higher incidence of congestive heart failure than other antihypertensive agents 1, 2
  • Important caveat: Alpha-blockers should not be assumed to constitute optimal management of concomitant hypertension; separate management may be needed 1, 2

Common side effects include: orthostatic hypotension, dizziness, tiredness (asthenia), ejaculatory problems, and nasal congestion 1, 2

Follow-up: Assess response at 4 weeks after initiating therapy 3

Second-Line Medical Therapy: 5-Alpha Reductase Inhibitors

5-alpha reductase inhibitors (finasteride, dutasteride) are appropriate for patients with LUTS associated with demonstrable prostatic enlargement, defined as prostate volume >30cc on imaging, PSA >1.5 ng/mL, or palpable prostate enlargement on DRE 1, 5

Key characteristics:

• Patients typically experience a 3-point improvement in AUA Symptom Index, which is generally perceived as meaningful 1, 2
• Critical limitation: These agents are ineffective in patients without enlarged prostates and should not be used in this population 1, 2
• Require 6-12 months to achieve maximum effect, which is a disadvantage compared to rapid relief from alpha-blockers 1
• Reduce risk of acute urinary retention and need for BPH-related surgery 1, 2, 5

Adverse effects: Primarily sexually related, including decreased libido, ejaculatory dysfunction, and erectile dysfunction; these are reversible 1, 5

Important safety consideration: The PCPT trial showed higher incidence of Gleason score 8-10 prostate cancer in men treated with finasteride (1.8%) versus placebo (1.4%) 5

Combination Therapy

5-alpha reductase inhibitors combined with alpha-blockers are recommended to prevent progression of LUTS/BPH and reduce risks of urinary retention and need for future prostate-related surgery 1

In the MTOPS study, combination therapy showed specific adverse effects more frequently than either drug alone: asthenia, postural hypotension, peripheral edema, dizziness, decreased libido, rhinitis, abnormal ejaculation, impotence, and abnormal sexual function 5

Management of Acute Urinary Retention

Initial treatment is catheterization followed by administration of an alpha-blocker prior to attempting catheter removal 2

• Alpha-blockers significantly improve trial without catheter success rates: alfuzosin (60% vs 39% for placebo), tamsulosin (47% vs 29% for placebo) 2
• Non-titratable alpha-blockers (tamsulosin or alfuzosin) are preferable for this indication 1
• Contraindications to alpha-blocker use: Prior history of alpha-blocker side effects or unstable medical comorbidities (orthostatic hypertension or cerebrovascular disease) 1

Surgical Indications

Surgery is recommended for patients with:

• Refractory urinary retention who have failed at least one attempt at catheter removal 1, 2
• Renal insufficiency clearly due to BPH 1, 2
• Recurrent UTIs clearly due to BPH and refractory to other therapies 1, 2
• Recurrent gross hematuria clearly due to BPH and refractory to other therapies 1, 2
• Bladder stones clearly due to BPH and refractory to other therapies 1, 2

For patients who are not surgical candidates: Treatment with intermittent catheterization, an indwelling catheter, or stent is recommended 1

Minimally Invasive Surgical Options

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 understanding that symptom improvement and flow rates are significantly inferior to TURP 6

• Achieves 73% response rate (≥30% reduction in IPSS) at 12 months, compared to 91% with TURP 6
• Demonstrates superior ejaculatory function preservation compared to TURP 6
• Maximum flow rate (Qmax) is significantly lower compared to TURP at all time points 6

For patients with prostate volume ≥80g or obstructing middle lobe: Alternative surgical options such as HoLEP, ThuLEP, or TURP should be considered 6

Critical Pitfalls to Avoid

• Never use 5-alpha reductase inhibitors in patients without prostatic enlargement as they are completely ineffective in this population 1, 2
• Balloon dilation is not recommended as a treatment option for BPH due to inadequate study results and significant failure rates over time 2
• Do not assume alpha-blockers adequately manage concomitant hypertension; separate antihypertensive management may be required 1, 2
• Inform patients with planned cataract surgery about IFIS risk before initiating alpha-blocker therapy 1
• Medical therapy is contraindicated in patients with gross hematuria who have not been adequately evaluated or in patients with microscopic hematuria alone 1