What is the treatment and diagnosis for Benign Prostatic Hyperplasia (BPH)?

Diagnosis and Treatment of Benign Prostatic Hyperplasia (BPH)

Diagnosis

BPH diagnosis requires quantifying symptom severity with the International Prostate Symptom Score (IPSS) or AUA Symptom Index, performing digital rectal examination to assess prostate size and morphology, measuring serum PSA, and obtaining urinalysis to exclude infection or hematuria. 1, 2, 3

Essential Initial Evaluation

• Symptom quantification using validated questionnaires (IPSS or AUA Symptom Index) objectively measures baseline severity and tracks treatment response 2, 3
• Digital rectal examination assesses prostate size, consistency, and nodularity; a lobulated, enlarged prostate supports BPH diagnosis 2
• Serum PSA measurement serves as a proxy for prostate volume and helps predict natural history and response to 5-alpha reductase inhibitors 1, 2
• Urinalysis identifies alternative causes including urinary tract infection, hematuria, or genitourinary malignancy 3

Critical Diagnostic Tests Before Treatment Selection

• Post-void residual (PVR) measurement is critical; volumes >200-350 mL indicate significant bladder dysfunction, predict poor response to medical therapy, and may require earlier surgical intervention 2
• Uroflowmetry with maximum flow rate (Qmax) <10 mL/sec suggests urodynamic obstruction and predicts better response to surgical rather than medical therapy 1, 2
• Prostate size estimation (by DRE or PSA as proxy) determines whether 5-alpha reductase inhibitor therapy is appropriate 1, 2

Optional Advanced Testing (Only When Indicated)

• Pressure-flow urodynamic studies are recommended only when considering surgery AND Qmax >10 mL/sec, or when concomitant neurologic disease (stroke, Parkinson's, neuropathy) is present 1, 2
• Cystoscopy is indicated only with history of hematuria, urethral stricture risk factors, bladder cancer history, or prior lower urinary tract surgery 1, 2
• Transrectal ultrasound is recommended only when selecting between minimally invasive or surgical interventions, particularly to guide choice between TUIP versus TURP 1, 2

Tests NOT Recommended

• Filling cystometrography and upper urinary tract imaging are not recommended unless the patient has hematuria, UTI, renal insufficiency, or history of urolithiasis or urinary tract surgery 1

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Treatment Algorithm

Mild Symptoms (Low IPSS/AUA Score)

Watchful waiting is the preferred management strategy for patients with mild symptoms. 1, 4

• Monitor yearly with repeat evaluations 4
• Implement lifestyle modifications: decrease fluid intake at bedtime, reduce caffeine and alcohol consumption 4

Moderate to Severe Symptoms: Medical Therapy

For prostates <30-40 cc, start with alpha-blocker monotherapy (tamsulosin 0.4 mg daily, alfuzosin, or doxazosin), which produces an average 4-6 point reduction in AUA Symptom Index within 3-5 days. 2, 4, 5

• Alpha-blockers (tamsulosin, alfuzosin, doxazosin) work by inhibiting alpha1-adrenergic-mediated contraction of prostatic smooth muscle, relieving bladder outlet obstruction 4, 6, 5
• Tamsulosin has lower risk of orthostatic hypotension but higher risk of ejaculatory dysfunction compared to other alpha-blockers 4
• Patients should be counseled about possible postural hypotension, dizziness when beginning therapy, and to inform ophthalmologists before cataract surgery 6

For prostates >30-40 cc, use combination therapy with alpha-blocker PLUS 5-alpha reductase inhibitor (finasteride 5 mg daily or dutasteride 0.5 mg daily) to reduce risk of symptomatic BPH progression, acute urinary retention, and need for surgery. 2, 7, 8, 9

• 5-alpha reductase inhibitors (finasteride, dutasteride) shrink prostate stroma, improve voiding, reduce future BPH-related surgery risk, and reduce acute urinary retention risk 7, 8, 5
• Finasteride should not be used in prostates <40 mL 2
• These agents require 6 months for full effect 2

Critical Treatment Pitfalls to Avoid

• Inadequate trial duration: declaring treatment failure before 4-12 weeks for alpha-blockers or 6 months for finasteride leads to premature escalation 2
• Ignoring prostate size: missing patients who would benefit from 5-alpha reductase inhibitor therapy; finasteride should not be used in prostates <40 mL 2
• Missing complications: large PVR, recurrent UTIs, hematuria, and renal insufficiency necessitate surgical rather than continued medical management 2

Adjunctive Medical Therapy

• PDE-5 inhibitors (tadalafil 5 mg daily) improve BPH-related symptoms and are FDA-approved for treating BPH 5, 9
• Anticholinergic/beta-3 agonist therapy can be added if persistent irritative storage symptoms remain after first-line BPH therapy 9, 10

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Surgical Intervention

Surgical intervention is appropriate when medical therapy fails after adequate trial, or when complications develop including refractory urinary retention, recurrent UTIs, bladder stones, renal insufficiency, or recurrent gross hematuria. 2, 4

Surgical Options

• TURP remains the benchmark surgical therapy with greatest efficacy based on randomized clinical trials with long-term follow-up 1, 4, 11
• TURP complications include sexual dysfunction, bladder neck contracture, need for blood transfusion, UTI, and hematuria 4
• Minimally invasive options (TUMT, TUNA, HoLEP, Greenlight laser, prostatic urethral lift) offer less morbidity with intermediate efficacy between medical therapy and TURP 1, 4, 11, 10
• Prostatic stents should be considered only in high-risk patients with urinary retention, as they are associated with significant complications including encrustation, infection, and chronic pain 4

Surgical Referral Indications

• Rising PSA (especially while on 5-alpha reductase inhibitor) 5
• Failure of urinary symptom control despite maximal medical therapy 5
• Suspicion of prostate cancer 5
• Hematuria 5
• Recurrent urinary infections 5
• Urinary retention 5
• Renal failure 5