What are the treatment options for an enlarged prostate?

Treatment Options for Enlarged Prostate (BPH)

For men with bothersome moderate-to-severe lower urinary tract symptoms (LUTS) from an enlarged prostate, alpha-blockers (alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin) should be first-line therapy, while 5-alpha reductase inhibitors (finasteride or dutasteride) are specifically indicated when prostate volume exceeds 30cc, PSA is >1.5 ng/mL, or palpable enlargement is present on digital rectal exam. 1, 2

Initial Assessment and Stratification

Before selecting treatment, determine:

• Symptom severity using the International Prostate Symptom Score (IPSS) or American Urological Association Symptom Index (AUASI) 1
• Prostate size via digital rectal exam (DRE), transrectal ultrasound (TRUS), or PSA as a proxy (PSA >1.5 ng/mL suggests volume >30cc) 1, 3
• Presence of complications including urinary retention, recurrent infections, renal insufficiency, or hematuria 1

Treatment Algorithm by Symptom Severity

Mild Symptoms (IPSS <8)

Watchful waiting is the preferred strategy for men with mild symptoms who have not developed BPH complications 1. This involves:

• Annual monitoring with repeat symptom assessment 1
• Lifestyle modifications: reduce evening fluid intake, limit caffeine and alcohol 1
• No active pharmacologic intervention unless symptoms progress 1

Moderate-to-Severe Symptoms (IPSS ≥8)

First-Line: Alpha-Blockers (Any Prostate Size)

Offer one of the following alpha-blockers as initial therapy: alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin 1. These agents:

• Improve IPSS by 4-7 points versus 2-4 points for placebo 1
• Work within 2-3 months regardless of prostate size 1, 4
• Are equally effective across all agents 1

Selection should be based on side effect profiles: 1

• Silodosin and tamsulosin: Higher rates of ejaculatory dysfunction (28% and 18% respectively) but less orthostatic hypotension 1
• Doxazosin and terazosin: Require dose titration, greater blood pressure effects 1
• Alfuzosin: Intermediate profile 1

Critical caveat: Before initiating alpha-blockers, inquire about planned cataract surgery and inform patients of intraoperative floppy iris syndrome (IFIS) risk; delay medication until after surgery if planned 1

Add or Switch to 5-Alpha Reductase Inhibitors (Enlarged Prostate Only)

Use 5-ARI monotherapy (finasteride 5mg daily or dutasteride 0.5mg daily) when prostate enlargement is confirmed by: 1, 2

• Prostate volume >30cc on imaging, OR
• PSA >1.5 ng/mL, OR
• Palpable enlargement on DRE

5-ARIs provide distinct benefits: 1, 2

• Reduce prostate volume by shrinking glandular tissue 2
• Prevent disease progression: reduce acute urinary retention risk by 57-67% and need for surgery by 55-64% over 4 years 2
• Improve symptoms by 3.3 points versus 1.3 points for placebo at 4 years 2
• Require 6-12 months for maximal symptom benefit (unlike alpha-blockers which work in weeks) 2, 4

Mandatory patient counseling before starting 5-ARIs: 1

• Sexual side effects (decreased libido, erectile dysfunction, ejaculatory disorders)
• Uncommon physical effects (gynecomastia, breast tenderness)
• PSA will decrease by approximately 50% after 6 months (must double PSA value when screening for prostate cancer) 2

Critical pitfall: DRE significantly underestimates prostate volume, particularly for glands 30-50cc (underestimation of 9-27%) 5. When TRUS is unavailable, use PSA >1.5 ng/mL as a reliable proxy for volume >30cc 3.

Combination Therapy (Enlarged Prostate with Severe Symptoms)

Combine an alpha-blocker with a 5-ARI for men with: 1, 2, 6

• Prostate volume >30cc (or PSA >1.5 ng/mL), AND
• Moderate-to-severe symptoms (IPSS ≥15-17), AND
• Desire to prevent long-term progression

Evidence from the MTOPS trial demonstrates combination therapy: 2, 6

• Reduces symptom progression by 64% versus placebo (versus 30% for finasteride alone, 46% for doxazosin alone) 2
• Reduces acute urinary retention by 81% versus placebo 2
• Reduces need for surgery by 67% versus placebo 2
• Provides greater symptom improvement than either monotherapy (mean reduction 7.4 points versus 5.6 for finasteride alone or 6.6 for doxazosin alone) 2

The benefit of combination therapy is greatest in men with larger prostates (mean 32g), higher baseline symptoms (mean IPSS 17), and elevated PSA (>1.5 ng/mL) 6.

When Medical Therapy Fails

Refer to urology for surgical evaluation when: 1

• Medical therapy fails to adequately control symptoms after 6 months (5-ARIs) or 2-3 months (alpha-blockers) 4
• Intolerable medication side effects occur 1
• Complications develop: recurrent urinary retention, recurrent urinary tract infections, bladder stones, renal insufficiency, or gross hematuria 1

Surgical options include: 1, 7

• Transurethral resection of prostate (TURP) - remains the benchmark procedure 1
• Transurethral incision of prostate (TUIP) - for smaller glands 1
• Minimally invasive therapies: transurethral microwave thermotherapy (TUMT), transurethral needle ablation (TUNA) 1
• Open prostatectomy - for very large glands 1

Follow-Up Strategy

Reassess at 3-6 months after initiating therapy using: 1

• Repeat IPSS scoring 1
• Global subjective assessment (patient's perception of improvement) 1

If IPSS improves and patient reports satisfaction: Continue current therapy 1

If IPSS unchanged but patient reports improvement: Discuss discrepancy; IPSS may not capture patient's priorities; consider continuing therapy 1

If IPSS worsens or patient dissatisfied: Reassess diagnosis, consider alternative treatments or urologic referral 1