What is the management approach for a male patient, likely in his 50s or older, diagnosed with Benign Prostatic Hyperplasia (BPH)?

Management of Benign Prostatic Hyperplasia

Initial Assessment and Risk Stratification

For men over 50 with BPH, begin by quantifying symptom severity using the International Prostate Symptom Score (IPSS/AUA Symptom Score): mild (<7), moderate (8-19), or severe (≥20), and critically assess whether symptoms are bothersome to the patient. 1, 2

• Measure prostate-specific antigen (PSA) in patients with ≥10-year life expectancy to exclude prostate cancer and predict BPH progression risk 1, 2
• Perform digital rectal examination to assess prostate size, exclude nodules suggesting malignancy, and estimate prostate volume 2, 3
• Obtain urinalysis to exclude urinary tract infection as a reversible cause of symptoms 3
• Measure post-void residual (PVR) urine volume to assess for significant obstruction, with volumes >300-350ml warranting urology referral 2

Treatment Algorithm Based on Symptom Severity

Mild Symptoms or Non-Bothersome Symptoms

Watchful waiting is the standard approach for patients with mild symptoms (IPSS <7) or those with moderate-to-severe symptoms who are not bothered by them, as treatment risks outweigh benefits in this population. 1, 2

• Schedule annual follow-up with repeat IPSS assessment and monitoring for disease progression or complications 1, 2

Moderate-to-Severe Bothersome Symptoms

Start with an alpha-blocker (tamsulosin, alfuzosin) as first-line therapy for all symptomatic patients, as these agents work regardless of prostate size and provide rapid symptom relief within 2-4 weeks. 1, 2

• Alpha-blockers relax prostatic smooth muscle, reducing the dynamic component of bladder outlet obstruction 1
• Reassess at 4 weeks after initiating alpha-blocker therapy using IPSS to objectively measure treatment response 1, 2
• Monitor for orthostatic hypotension and dizziness during initial treatment 2

Alternative first-line option: For patients with concurrent erectile dysfunction, PDE5 inhibitors (tadalafil 5mg daily) can be started as initial therapy instead of alpha-blockers 1

Combination Therapy for Enlarged Prostates

For patients with enlarged prostates >30-40cc (or PSA >1.5 ng/mL) and moderate-to-severe symptoms, add a 5-alpha reductase inhibitor (finasteride 5mg daily or dutasteride 0.5mg daily) to the alpha-blocker. 1, 2, 4, 5

• Combination therapy addresses both dynamic and static components of obstruction and reduces risk of symptomatic progression, acute urinary retention (57% risk reduction), and need for surgery (48% risk reduction) 1, 4, 5
• 5-ARIs reduce prostate volume by approximately 18-25% over 6-12 months 3, 5
• Counsel patients about potential sexual side effects (erectile dysfunction, decreased libido, ejaculation disorders) that may persist after discontinuation 4
• Assess efficacy at minimum 3-6 months, with maximum benefit at 12 months 1, 2
• PSA levels will decrease by approximately 50% after 6 months of 5-ARI therapy; any rise in PSA while on treatment warrants urology referral 2

Mandatory Urology Referral Criteria

Immediately refer patients with absolute indications for surgery to urology: 1, 2, 3

• Refractory urinary retention requiring catheterization
• Recurrent urinary tract infections despite treatment
• Recurrent gross hematuria
• Bladder stones
• Renal insufficiency secondary to BPH
• Upper tract dilatation with hydronephrosis
• Large post-void residual volumes (>300-350ml)

Follow-Up Monitoring Strategy

• For alpha-blockers and PDE5 inhibitors: first follow-up at 4 weeks 1
• For 5-ARIs: wait 3-6 months before assessing efficacy 1
• Once stable on treatment, schedule follow-up intervals at least yearly, repeating IPSS assessment to detect symptom progression or complications 1, 2
• Patients who fail to improve or experience intolerable side effects should undergo further evaluation and consideration of surgical intervention 1

Surgical Intervention

Transurethral resection of the prostate (TURP) remains the gold standard surgical approach for patients who fail medical therapy after 6 months of combination treatment, develop complications, or have absolute indications for surgery. 1, 3

Critical Pitfalls to Avoid

• Do not delay evidence-based medical therapy while patients trial unproven treatments like saw palmetto, as this allows disease progression and potential complications including acute urinary retention 2
• Do not treat patients with non-bothersome symptoms regardless of severity, as treatment risks outweigh benefits 1, 2
• Do not assume all voiding dysfunction in elderly males is due to BPH; detrusor underactivity from aging or diabetes can produce identical symptoms but requires different management 3
• Do not attribute hematuria solely to BPH without excluding bladder stones, bladder cancer, or upper tract pathology 3
• Be aware that 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