What are the guidelines for managing Benign Prostatic Hyperplasia (BPH)?

Management of Benign Prostatic Hyperplasia (BPH)

Initial Evaluation

All patients with bothersome lower urinary tract symptoms (LUTS) should undergo a medical history, physical examination including digital rectal examination (DRE), International Prostate Symptom Score (IPSS) assessment, and urinalysis. 1, 2

• The IPSS questionnaire (7 questions scored 0-5 each, total 0-35 points) quantifies symptom severity: mild (0-7), moderate (8-19), or severe (20-35) 1
• Physical examination must assess for bladder distention and neurologic impairment 3
• Serum PSA measurement helps predict natural history, risk of acute urinary retention, and response to 5-alpha reductase inhibitors 1
• Optional tests (pressure-flow urodynamic studies, cystoscopy, transrectal ultrasound) are reserved for patients choosing invasive therapies or when results would change management 1
• Not recommended: Filling cystometry and upper urinary tract imaging unless hematuria, recurrent infections, or renal insufficiency are present 1

Treatment Algorithm Based on Symptom Severity

Mild Symptoms (IPSS 0-7)

Watchful waiting is the preferred management strategy for patients with mild symptoms. 1, 2

• Monitor patients yearly with repeat IPSS and initial evaluation 1, 2
• Implement lifestyle modifications: decrease fluid intake at bedtime, reduce caffeine and alcohol consumption, avoid decongestants and antihistamines, bladder training, and timed voiding 2
• Advise patients on individual risk based on prostate volume and PSA levels 1, 2

Moderate to Severe Symptoms (IPSS ≥8) - Medical Therapy

Alpha-adrenergic blockers are first-line medical therapy for symptomatic BPH. 1, 3

Alpha-Blockers (First-Line)

• Alfuzosin, doxazosin, tamsulosin, and terazosin have equal clinical effectiveness and produce 4-6 point improvement in IPSS 1
• Onset of action: 3-5 days 4
• Dosing: Doxazosin up to 8 mg, tamsulosin 0.4-0.8 mg, terazosin up to 10 mg 1
• Side effects: orthostatic hypotension, dizziness, asthenia, ejaculatory dysfunction, nasal congestion 1
• Tamsulosin (alpha-1A selective) requires no dose titration and has minimal blood pressure effects 5
• Prazosin and phenoxybenzamine are not recommended due to insufficient data 1

5-Alpha Reductase Inhibitors

Finasteride and dutasteride are indicated for men with enlarged prostates (>40 mL) to improve symptoms, reduce acute urinary retention risk, and decrease need for surgery. 6, 4

• Requires 6 months to assess effectiveness and 12 months for maximum benefit 5
• Reduces prostate size by inhibiting conversion of testosterone to dihydrotestosterone 1
• Efficacy dependent on prostate volume; not effective in prostates <40 mL 5
• Reduces PSA by approximately 50% after 6-12 months 6

Combination Therapy

Finasteride combined with doxazosin reduces risk of symptomatic BPH progression (≥4 point increase in AUA symptom score) 6

Phosphodiesterase-5 Inhibitors

Tadalafil 5 mg once daily is FDA-approved for BPH treatment and improves LUTS. 7, 4, 8

• Can be used alone or with finasteride (up to 26 weeks studied) 7
• Not recommended in combination with alpha-blockers for BPH due to additive vasodilatory effects and blood pressure lowering 7
• Patients on alpha-blockers for BPH must discontinue at least one day before starting tadalafil 7
• Contraindicated with nitrates 7
• Dose adjustments required for renal impairment (CrCl 30-50: start 2.5 mg; CrCl <30: not recommended) 7

Surgical Referral Indications

Refer to urology for: 4, 3

• Renal insufficiency secondary to BPH 1
• Recurrent urinary retention 1
• Recurrent urinary tract infections 1
• Bladder stones 1
• Gross hematuria of prostatic origin 1
• Failure of medical therapy 3
• Rising PSA, especially on 5-alpha reductase inhibitors 4

Surgical Options

• Transurethral resection of prostate (TURP): Most effective therapy but 20% complication rate 5
• Transurethral incision of prostate (TUIP): Effective for prostates <30 g with minimal adverse effects 5
• Minimally invasive procedures: HoLEP, Greenlight laser, prostatic urethral lift, transurethral microwave therapy 9

Critical Caveats

• Do not assume all LUTS in older men are due to BPH; overactive bladder and other conditions may coexist 2
• Symptom severity (IPSS score) does not correlate with physiological obstruction; patient bother should guide treatment decisions 2
• Tadalafil and alpha-blockers should not be combined for BPH treatment due to hypotension risk 7
• Dietary supplements (saw palmetto, pygeum) are not recommended 3
• Medical therapy is contraindicated in patients with inadequately evaluated hematuria 1