What are the treatment options for a male patient over 50 with benign prostatic hyperplasia (BPH)?

Treatment of Benign Prostatic Hyperplasia

Initial Management Strategy

For men over 50 with bothersome moderate-to-severe BPH symptoms (AUA Symptom Score ≥8), alpha-blockers (alfuzosin, tamsulosin) are the recommended first-line therapy, providing rapid symptom relief within 2-4 weeks. 1, 2, 3

For patients with mild symptoms (AUA Symptom Score <7) or those with moderate-to-severe symptoms who are not bothered by them, watchful waiting is the standard approach, as the risks of medical therapy outweigh benefits in this population. 1

Medical Therapy Algorithm

First-Line Treatment: Alpha-Blockers

• Start with an alpha-blocker (tamsulosin 0.4 mg once daily, alfuzosin, doxazosin, or terazosin) for all symptomatic patients, as these agents work regardless of prostate size and provide the fastest symptom relief. 1, 2, 4

• Alpha-blockers relax prostatic smooth muscle, reducing the dynamic component of bladder outlet obstruction. 3

• Tamsulosin requires no dose titration and has minimal blood pressure effects, while non-selective agents (terazosin, doxazosin) are preferable in hypertensive patients. 5, 6

• Reassess patients 4-12 weeks after initiating alpha-blocker therapy using the International Prostate Symptom Score (IPSS) to objectively measure treatment response. 1, 4

Adding 5-Alpha Reductase Inhibitors (5-ARIs)

• For patients with enlarged prostates >30cc, add a 5-ARI (finasteride 5 mg daily or dutasteride) to the alpha-blocker. 1, 2, 3

• 5-ARIs (finasteride, dutasteride) reduce prostate volume and prevent disease progression by blocking conversion of testosterone to dihydrotestosterone. 2, 7

• Finasteride requires 6-12 months to achieve maximum effect and should not be used in prostates <40 mL, as efficacy is size-dependent. 5, 6

• Combination therapy (alpha-blocker plus 5-ARI) is specifically recommended for patients with moderate-to-severe symptoms AND prostate enlargement, as it addresses both dynamic and static components of obstruction and reduces risk of symptomatic progression. 1, 2, 7

Alternative Medical Options

• Phosphodiesterase-5 inhibitors (PDE5s) can be used as initial therapy in patients who also have erectile dysfunction. 1

• Anticholinergics or beta-3 agonists may be added for patients with predominant storage symptoms (urgency, frequency) after excluding bladder outlet obstruction. 1

Surgical Intervention

Transurethral resection of the prostate (TURP) remains the gold standard surgical approach for patients who fail medical therapy, develop complications, or have absolute indications for surgery. 3, 5

Indications for Surgery

Absolute indications requiring surgical referral include: 1

• Refractory urinary retention
• Recurrent urinary tract infections due to BPH
• Recurrent gross hematuria due to BPH
• Bladder stones due to BPH
• Renal insufficiency due to BPH
• Upper tract dilatation with hydronephrosis

Alternative Surgical Options

Minimally invasive procedures (holmium laser enucleation, Greenlight laser, prostatic urethral lift, transurethral microwave therapy) offer shorter hospitalization and can be performed in high-risk patients, with efficacy between TURP and medical therapy. 5, 8

Critical Pitfalls to Avoid

• Do not use saw palmetto, as current guidelines exclude it due to lack of strong evidence for clinical effectiveness. 2

• Do not delay evidence-based medical therapy while patients trial ineffective treatments, as this allows disease progression and potential complications including acute urinary retention. 2

• Do not add 5-ARIs unless prostate volume exceeds 30cc, as they are ineffective in smaller glands and require 6-12 months to show benefit. 1, 4, 5

• Do not assume all LUTS are due to BPH—exclude bladder cancer, urethral strictures, neurologic disease, and urinary tract infections through urinalysis and focused examination. 1

• Do not measure post-void residual (PVR) as a contraindication to medical therapy, as large PVRs (even 200-300 mL) do not predict medical therapy response and many patients maintain elevated PVRs without complications. 1

Follow-Up Strategy

• For alpha-blockers, PDE5s, and anticholinergics (fast-onset drugs), schedule first follow-up at 4 weeks. 1

• For 5-ARIs (slow-onset drugs), wait 3-6 months before assessing efficacy. 1

• Patients who fail to improve or experience intolerable side effects should undergo further evaluation and consideration of surgical intervention. 1

• Once stable on treatment, follow-up intervals should be at least yearly, repeating initial evaluation to detect symptom progression or complications. 1

Special Considerations

• Measure serum PSA in patients with ≥10-year life expectancy to exclude prostate cancer and predict BPH progression risk, as higher PSA levels correlate with future prostate growth, symptom deterioration, and acute urinary retention. 1, 3

• Sexual adverse effects (erectile dysfunction, decreased libido, ejaculation disorders) occur in 3.7-8.1% with finasteride and 12.2-22.6% with combination therapy, and may rarely persist after discontinuation. 7

• The incidence of acute urinary retention increases dramatically with age, from 6.8 per 1,000 patient-years overall to 34.7 per 1,000 in men aged ≥70 years. 1, 3