From the Guidelines
The best procedure for BPH is transurethral resection of the prostate (TURP), as it remains the gold standard surgical procedure for removing obstructing prostate tissue through the urethra, providing significant symptom relief for patients with moderate to severe symptoms. When considering treatment options for BPH, it's essential to evaluate symptom severity, prostate size, and patient preferences. For mild symptoms, watchful waiting with lifestyle modifications may be sufficient. However, for moderate to severe symptoms, medications are typically the first-line treatment, including alpha-blockers and 5-alpha reductase inhibitors, which can provide quick symptom relief and shrink the prostate over time 1. Some key points to consider when evaluating treatment options for BPH include:
- The size and shape of the prostate, as measured by ultrasound, can predict the natural history of BPH and response to therapy with 5 alpha-reductase inhibitors 1.
- Pressure-flow urodynamic studies can directly measure the relative contribution of the bladder and bladder outlet and the contributions of the prostate to lower urinary tract function, dysfunction, or symptoms, and are considered optional in men prior to invasive therapy 1.
- Urethrocystoscopy may be appropriate in men with a history of microscopic or gross hematuria, urethral stricture, or prior lower urinary tract surgery, but is not routinely necessary prior to watchful waiting or medical therapy 1.
- Newer, less invasive options, such as laser procedures, UroLift, Rezum, and prostate artery embolization, aim to reduce urinary obstruction by removing or displacing prostate tissue that blocks urine flow, improving symptoms by addressing the underlying mechanical obstruction caused by prostate enlargement. It's crucial to weigh the potential benefits and risks of each treatment option and consider the individual patient's needs and preferences when making a decision. Ultimately, TURP remains the most effective surgical procedure for providing long-term symptom relief for patients with moderate to severe BPH symptoms.
From the FDA Drug Label
1.1 Monotherapy Finasteride tablets are indicated for the treatment of symptomatic benign prostatic hyperplasia (BPH) in men with an enlarged prostate to:
- Improve symptoms
- Reduce the risk of acute urinary retention
- Reduce the risk of the need for surgery including transurethral resection of the prostate (TURP) and prostatectomy.
- 1 Monotherapy Finasteride tablets 5 mg/day was initially evaluated in patients with symptoms of BPH and enlarged prostates by digital rectal examination in two 1-year, placebo-controlled, randomized, double-blind studies and their 5-year open extensions
The best procedure for BPH is not explicitly stated in the provided drug labels as a "procedure", but rather finasteride tablets are indicated for the treatment of symptomatic BPH to improve symptoms, reduce the risk of acute urinary retention, and reduce the risk of the need for surgery, including transurethral resection of the prostate (TURP) and prostatectomy 2 2.
- Key benefits of finasteride tablets include:
- Improvement in symptom score
- Reduction in risk of acute urinary retention
- Reduction in risk of the need for BPH-related surgery However, the FDA label does not provide a direct comparison of different procedures for BPH.
From the Research
Treatment Options for BPH
The treatment options for Benign Prostatic Hyperplasia (BPH) include lifestyle modification, smooth muscle relaxant alpha blocker therapy, 5-alpha reductase inhibitors, and surgical procedures such as transurethral resection of the prostate (TURP) or open prostatectomy 3, 4.
Medical Therapy
Medical therapy is becoming increasingly important in the treatment of patients with moderate symptoms of BPH. Alpha blockers, such as tamsulosin, alfusosin, and silodosin, are effective in managing BPH-related lower urinary tract symptoms (LUTS) and improving the maximal urinary flow rate 3, 4. 5-alpha reductase inhibitors, such as finasteride and dutasteride, are effective in reducing prostate size and preventing disease progression in longer-term treatment 4, 5.
Combination Therapy
Combination therapy using alpha-1 adrenergic receptor antagonists (ARAs) and 5-alpha reductase inhibitors (5-ARIs) has been shown to be effective in treating BPH patients at risk of clinical progression 6, 5. The results of several studies, including the Medical Therapy of Prostatic Symptoms (MTOPS) study and the CombAT trial, suggest that combination therapy with ARAs and 5-ARIs is beneficial in the treatment of BPH and the associated symptoms, particularly in patients with an enlarged prostate, more severe symptoms, and higher PSA levels 5, 7.
Surgical Procedures
Surgical procedures, such as TURP or open prostatectomy, are currently the most effective therapies for BPH, but are associated with clinically significant adverse events in some patients 4. Minimally invasive procedures, such as electrovaporisation, laser prostatectomy, and transurethral microwave therapy, can be performed instead of standard surgical procedures and have a lower risk of adverse events 4.
Key Considerations
When considering treatment options for BPH, it is essential to take into account the patient's preference, symptom severity, prostate size, and PSA levels 4, 5. Referral to a urologist can be considered for patients with a rising PSA, especially while on 5-ARI, failure of urinary symptom control despite maximal medical therapy, suspicion of prostate cancer, hematuria, recurrent urinary infections, urinary retention, or renal failure 3.