Should primary care treat Benign Prostatic Hyperplasia (BPH) in middle-aged to elderly men?

Should Primary Care Treat BPH?

Yes, primary care physicians should treat BPH for patients with mild to moderate symptoms, initiating watchful waiting or medical therapy, while referring complicated cases or those requiring surgical intervention to urology. 1, 2

Primary Care Role in BPH Management

Primary care physicians are well-positioned to manage the majority of BPH cases, as the treatment needs of men with mild to moderate lower urinary tract symptoms without evidence of prostate cancer can be accomplished in a primary care setting. 2 The American Urological Association guidelines explicitly direct both primary care and urologic providers toward streamlined and appropriate practices for BPH evaluation and medical management. 1

Initial Evaluation and Risk Stratification

Primary care should perform the following assessment:

• Symptom quantification using the International Prostate Symptom Score (IPSS/AUA Symptom Score) to categorize severity: mild (<7), moderate (8-19), or severe (≥20) 1, 3
• Digital rectal examination (DRE) to assess prostate size and detect nodules 3, 4
• Assessment of symptom bother - this is critical as patients with even severe symptoms who are not bothered should not receive active treatment 1
• Prostate-specific antigen (PSA) testing to assess cancer risk and predict disease progression 1, 3

When Primary Care Should Manage BPH

Mild symptoms (AUA Score <7) or non-bothersome symptoms of any severity:

• Watchful waiting is the standard approach with annual follow-up 1
• No active treatment is indicated as risks outweigh benefits 1

Bothersome moderate symptoms (AUA Score 8-19):

• First-line therapy: Alpha-blockers (tamsulosin, alfuzosin, silodosin) provide rapid symptom relief within 3-5 days with minimal side effects 5, 3, 6
• For enlarged prostates (>40ml or PSA >1.5 ng/mL): 5-alpha reductase inhibitors (finasteride 5mg daily, dutasteride) to shrink prostate volume and prevent disease progression 5, 7, 3
• Combination therapy (alpha-blocker plus 5-ARI) for patients with moderate-to-severe symptoms and prostate enlargement addresses both dynamic and static obstruction components 5, 7
• PDE-5 inhibitors (tadalafil 5mg daily) may be considered for BPH symptom improvement 3, 8

Mandatory Referral Criteria to Urology

Primary care must refer patients with the following conditions, as these require urologic expertise:

• Absolute indications for surgery: Refractory urinary retention, recurrent urinary tract infections, bladder stones, renal insufficiency due to BPH, or gross hematuria 1
• Rising PSA while on 5-ARI therapy (suggests possible prostate cancer) 3
• Failure of maximal medical therapy to control symptoms 3, 8
• Suspicion of prostate cancer based on abnormal DRE or elevated PSA 3, 4
• Recurrent hematuria or urinary infections 3
• Large post-void residual volumes (>300-350ml) suggesting bladder dysfunction 1
• Upper tract dilatation or elevated creatinine 1

Treatment Monitoring in Primary Care

For patients on alpha-blockers:

• Assess treatment response at 2-4 weeks after initiation 1
• Monitor for orthostatic hypotension and dizziness (except with tamsulosin which is alpha-1A selective) 6

For patients on 5-alpha reductase inhibitors:

• Assess effectiveness at minimum 3 months, with maximum benefit at 12 months 1, 6
• PSA values will decrease by approximately 50% - any rise in PSA while on therapy warrants urologic referral 3
• Counsel patients about sexual side effects (erectile dysfunction, decreased libido, ejaculatory dysfunction) and potential for persistent sexual dysfunction after discontinuation 7

Annual follow-up for stable patients:

• Repeat symptom score assessment 1
• Monitor for disease progression or complications 1

Critical Pitfalls to Avoid

• Do not delay evidence-based medical therapy while patients trial unproven therapies like saw palmetto, as this allows disease progression and potential complications including acute urinary retention 5
• Do not treat patients with non-bothersome symptoms regardless of severity, as treatment risks outweigh benefits 1
• Do not assume all LUTS are due to BPH - men with normal flow rates (Qmax >10 ml/sec) may have non-prostatic causes requiring further investigation 1
• Remember to double the PSA value when interpreting results in patients on 5-ARI therapy for at least 6 months 7
• Be aware of increased risk of high-grade prostate cancer (Gleason 8-10) with finasteride use, though clinical significance remains uncertain 7

The Shared Care Model

A collaborative approach between primary care and urology represents the optimal model for BPH management. 2 Primary care physicians handle initial diagnosis, medical management of uncomplicated cases, and ongoing monitoring, while urologists manage complex cases, surgical candidates, and patients with concerning features requiring specialized evaluation. 2, 4 This approach maximizes efficiency and ensures patients receive appropriate care at the right level of complexity.