What is the recommended treatment for a patient with moderate to severe Benign Prostatic Hyperplasia (BPH) symptoms?

Treatment of Moderate to Severe Benign Prostatic Hyperplasia

For patients with bothersome moderate to severe BPH symptoms (AUA Symptom Score >8), alpha-adrenergic blockers should be initiated as first-line medical therapy, as they provide superior and more rapid symptom relief (4-6 point improvement in symptom scores within 2-4 weeks) compared to other medical options. 1, 2

Initial Treatment Selection

Alpha-Blocker Monotherapy (First-Line)

• Start with an alpha-blocker (alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin) as these agents work regardless of prostate size and provide the fastest symptom relief 1, 3
• All alpha-blockers demonstrate similar efficacy with 4-6 point IPSS improvement that patients perceive as meaningful 1, 2
• Choose based on side effect profile:
  • Tamsulosin or silodosin: Lower risk of orthostatic hypotension but higher risk of ejaculatory dysfunction 1, 4, 3
  • Doxazosin or terazosin: Require dose titration, higher risk of orthostatic hypotension and dizziness 1
  • Alfuzosin: Intermediate adverse effect profile 1

Critical Caveat for Cataract Surgery

• Before initiating alpha-blockers, ask about planned cataract surgery - these medications increase risk of intraoperative floppy iris syndrome (IFIS) 1
• Consider delaying alpha-blocker initiation until after cataract surgery is completed 1

When to Consider 5-Alpha-Reductase Inhibitors

5-ARI Monotherapy

• Reserve 5-ARIs (finasteride 5 mg daily or dutasteride) for patients with documented prostate enlargement who prefer to avoid alpha-blocker side effects 1, 2, 5
• 5-ARIs are less effective for symptom improvement (3-point vs 4-6 point IPSS improvement) and require 6 months to assess effectiveness 1
• Major advantage: Reduce risk of acute urinary retention and need for BPH-related surgery 1, 5
• Important counseling points:
  • Sexual dysfunction (decreased libido, erectile dysfunction, ejaculatory disorders) occurs in 6-8% 5
  • PSA decreases by approximately 50% (must double PSA values for prostate cancer screening) 1, 5
  • Potential increased risk of high-grade (Gleason 8-10) prostate cancer 1, 5

Combination Therapy Strategy

Prescribe combination therapy (alpha-blocker + 5-ARI) for patients with enlarged prostates who are at risk of disease progression to further reduce risk of urinary retention and need for surgery beyond either monotherapy 1, 2, 5

• Best-studied combination: doxazosin plus finasteride 1, 5
• Expect additive adverse effects: Higher incidence of asthenia, postural hypotension, peripheral edema, dizziness, and sexual dysfunction compared to monotherapy 1, 5

Watchful Waiting Alternative

Watchful waiting remains appropriate for patients with moderate to severe symptoms who are not bothered enough to pursue active treatment after counseling on benefits and harms of all options 6, 1

• Monitor yearly with repeat symptom assessments 1
• Implement lifestyle modifications: reduce evening fluid intake, limit caffeine and alcohol 1

Absolute Indications for Surgical Referral

Surgery is mandatory (not optional) for patients with BPH-related complications 6, 2:

• Refractory urinary retention (failed at least one catheter removal attempt) 6
• Renal insufficiency clearly due to BPH 6
• Recurrent urinary tract infections refractory to other therapies 6
• Recurrent gross hematuria (proven prostatic origin) refractory to therapy 6
• Bladder stones clearly due to BPH 6

Surgical Options

• TURP remains the benchmark surgical therapy with strongest long-term efficacy data 1
• Alternative surgical options include TUIP, transurethral electrovaporization, laser procedures, and open prostatectomy 6, 1
• Minimally invasive therapies (TUMT, TUNA) have efficacy between TURP and medical therapy, reserved for medical therapy failures 1

Follow-Up Protocol

• Monitor treatment response using IPSS scores and patient-reported global assessment 1
• Continue therapy if patient reports improvement matching IPSS improvement 1
• Reassess and discuss alternative treatments if patient reports neutral/worsening response despite stable/improved IPSS - this indicates treatment failure 1