What are the preoperative considerations for an older adult male with a history of Benign Prostatic Hyperplasia (BPH) who is currently on finasteride and scheduled for a surgical procedure?

Preoperative Management of BPH Patient on Finasteride

For an older adult male with BPH on finasteride scheduled for surgery, continue finasteride through the perioperative period as it reduces surgical blood loss, and complete mandatory preoperative assessments including post-void residual, urinalysis, and consideration of prostate size measurement. 1

Preoperative Evaluation Requirements

Mandatory Assessments

• Medical history and AUA-Symptom Index to document baseline symptom severity 1
• Urinalysis to screen for infection or hematuria 1, 2
• Post-void residual (PVR) assessment must be performed prior to any surgical intervention for LUTS/BPH 1
• Digital rectal examination to assess prostate characteristics and exclude locally advanced disease 2

Strongly Recommended Assessments

• Prostate size and shape assessment via abdominal or transrectal ultrasound, cystoscopy, or existing cross-sectional imaging (MRI/CT) should be considered before surgical intervention 1
• Uroflowmetry should be considered preoperatively, as men with Qmax <10 mL/sec are more likely to have urodynamic obstruction and improve with surgery 1, 3

Finasteride-Specific Considerations

Continue Finasteride Perioperatively

Finasteride should be continued through the perioperative period as preoperative use for as little as 2 weeks significantly reduces perioperative blood loss during TURP. 4 The study demonstrated:

• Significantly lower reduction in hemoglobin and hematocrit in finasteride-treated patients (P < 0.05) 4
• Significantly decreased microvessel density in prostate tissue (artery P = 0.005, vein P = 0.05, gland P = 0.008) 4

Finasteride Effects on Surgical Planning

• Prostate volume reduction of approximately 20% occurs with finasteride treatment, which may influence surgical approach selection 5
• Finasteride reduces serum DHT by approximately 70% with daily 5 mg dosing 5
• Effects on prostate size return to near baseline approximately 3 months after discontinuation 5

PSA Interpretation in Finasteride Users

Critical caveat: Finasteride reduces serum PSA levels by approximately 50% after 6 months of treatment 5. For cancer screening purposes:

• Double the PSA value in patients on finasteride for ≥6 months to approximate the actual PSA 5
• The ratio of free to total PSA (percent free PSA) remains constant and requires no adjustment 5
• Any confirmed increase in PSA while on finasteride warrants careful evaluation for prostate cancer 5

Assessment of Comorbidities and Surgical Risk

Urological Considerations

• Evaluate for large residual urinary volume and severely diminished urinary flow, as these patients require careful monitoring for obstructive uropathy and may not be surgical candidates 5
• Consider that prostate cancer and BPH may coexist; ensure appropriate cancer screening has been performed 5

Medication Review

• Identify medications that worsen urinary symptoms: anticholinergics (antihistamines, tricyclic antidepressants), diuretics, and alpha-agonists (decongestants) 3
• Review for conditions affecting bladder function (neurologic disease, diabetes) that may impact surgical outcomes 1, 2

Counseling Requirements

Sexual Function Discussion

Patients must be counseled about sexual side effects of surgical intervention, including:

• Risk of ejaculatory dysfunction 1
• Potential worsening of erectile dysfunction 1
• Given the strong relationship between ED and LUTS/BPH, this population is at high risk for sexual dysfunction 1

Shared Decision-Making

• Provide the complete risk/benefit profile for all treatment options in the context of the patient's specific circumstances 1
• Discuss that surgical intervention is appropriate for moderate-to-severe LUTS and for patients with BPH-related complications 1

Special Considerations for High-Risk Patients

• If the patient has significant comorbidities making standard surgery high-risk, prostatic stents may be considered, though they are associated with complications including encrustation, infection, and chronic pain 1
• Patients with urinary retention or who are too ill for other treatments may require alternative approaches 1

Common Pitfalls to Avoid

• Do not discontinue finasteride preoperatively – it provides benefit in reducing surgical blood loss 4
• Do not forget to adjust PSA interpretation in patients on finasteride for cancer screening purposes 5
• Do not proceed with surgery without assessing PVR – this is a mandatory preoperative test 1
• Do not assume normal renal function – patients with large PVR volumes (e.g., 350 mL) may have bladder dysfunction and should be monitored for obstructive uropathy 5