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

Treatment of Benign Prostatic Hyperplasia

First-Line Medical Therapy

For men over 50 with bothersome moderate-to-severe BPH symptoms, start with an alpha-blocker as first-line therapy, which provides rapid symptom relief within 2-4 weeks regardless of prostate size. 1

Alpha-Blocker Selection and Dosing

• Tamsulosin 0.4 mg once daily is administered approximately one-half hour following the same meal each day, with no dosage titration required due to its alpha-1A receptor specificity 2
• For patients who fail to respond after 2-4 weeks, the tamsulosin dose can be increased to 0.8 mg once daily 2
• Alternative alpha-blockers include terazosin and doxazosin, which require dose titration but offer the advantage of blood pressure reduction in hypertensive patients 3, 4
• Alpha-blockers work by relaxing prostatic smooth muscle, reducing the dynamic component of bladder outlet obstruction 1

When to Add 5-Alpha Reductase Inhibitor

For patients with prostates >30cc, add finasteride 5 mg daily to the alpha-blocker regimen. 1

• Combination therapy (alpha-blocker plus 5-ARI) addresses both dynamic and static components of obstruction and reduces risk of symptomatic progression 1
• Finasteride is indicated as monotherapy to improve symptoms, reduce risk of acute urinary retention, and reduce need for surgery including TURP 5
• Critical timing consideration: Finasteride requires 3-6 months before assessing efficacy, compared to 4 weeks for alpha-blockers 1
• Finasteride reduces prostate volume and is most effective in patients with prostate volume ≥40 mL 4

Special Population: Erectile Dysfunction

• If the patient also has erectile dysfunction, PDE5 inhibitors can be started as initial therapy instead of alpha-blockers 3

Watchful Waiting Alternative

• For patients with mild symptoms (IPSS 0-7) 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

Follow-Up Protocol

Initial Assessment Timing

• For alpha-blockers: Schedule first follow-up at 4 weeks to assess response using IPSS 1
• For 5-ARIs: Wait 3-6 months before assessing efficacy due to delayed mechanism of action 1
• Reassessment should include IPSS and may include post-void residual and uroflowmetry 3

Long-Term Monitoring

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

Surgical Referral Indications

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

Absolute Indications for Surgery

Immediate surgical referral is required for: 1

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

Gold Standard Procedure

• Transurethral resection of the prostate (TURP) remains the gold standard surgical approach for patients who fail medical therapy or develop complications 1

Common Adverse Effects and Management

Alpha-Blocker Side Effects

• Dizziness, postural hypotension, and asthenia occur more frequently with non-selective alpha-blockers like doxazosin (15.7-17.7%) compared to placebo 5
• Tamsulosin lacks significant blood pressure effects due to alpha-1A receptor specificity, eliminating need for dose titration 4

5-ARI Side Effects

• Sexual dysfunction is the most common adverse effect: impotence (8.1% vs 3.7% placebo in year 1), decreased libido (6.4% vs 3.4% placebo), and decreased ejaculate volume (3.7% vs 0.8% placebo) 5
• In years 2-4 of treatment, sexual side effects equilibrate between finasteride and placebo groups 5
• 3.7% of patients discontinued finasteride due to sexual function adverse reactions 5

Combination Therapy Considerations

• Combination therapy with finasteride and doxazosin produces additive side effects, particularly abnormal ejaculation (14.1% vs 7.2% finasteride alone vs 4.5% doxazosin alone) 5
• The incidence of impotence with combination therapy (22.6%) exceeds either monotherapy 5

Critical Clinical Pitfalls

PSA Monitoring

• Measure serum PSA in patients with ≥10-year life expectancy to exclude prostate cancer and predict BPH progression risk 1
• Finasteride decreases PSA by 50% as an effect on epithelial cells, which must be accounted for when screening for prostate cancer 6

Drug Interruption

• If tamsulosin is discontinued or interrupted for several days at either 0.4 mg or 0.8 mg dose, restart therapy with 0.4 mg once-daily dose 2

High-Grade Prostate Cancer Risk

• The PCPT trial demonstrated higher incidence of Gleason score 8-10 prostate cancer in men treated with finasteride (1.8%) versus placebo (1.4%), though finasteride is not approved for prostate cancer prevention 5

Age-Related Progression

• 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
• Nearly 50% of men develop moderate-to-severe LUTS by age 80 3