How to approach a male patient over 50 with symptoms of benign prostatic hyperplasia (BPH), such as urinary hesitancy, frequency, or nocturia?

Approach to BPH Symptoms in Men Over 50

Start with the International Prostate Symptom Score (IPSS) at the initial visit, obtain a focused history including sexual function and medications, perform digital rectal exam and urinalysis, and initiate alpha-blocker therapy for bothersome moderate-to-severe symptoms unless the prostate is enlarged (>30cc), in which case consider adding a 5-alpha reductase inhibitor. 1, 2

Initial Evaluation Components

Required Assessment Tools

• Administer the IPSS (AUA Symptom Index) to every patient at first presentation to quantify symptom severity (mild 0-7, moderate 8-19, severe 20-35) and assess the single quality-of-life question measuring patient bother 1, 2, 3
• The IPSS is superior to unstructured interviews for quantifying symptoms and must be readministered at each follow-up visit to objectively track changes 2, 3
• Add a frequency-volume chart (voiding diary) when nocturia predominates, recording time and volume for each void over 3 consecutive 24-hour periods to identify nocturnal polyuria or excessive fluid intake 1, 2

Required History Elements

• Focus on nature and duration of genitourinary symptoms, previous genitourinary surgeries, sexual function status, and current medications that may worsen LUTS (anticholinergics, decongestants, diuretics) 1
• Assess overall fitness for potential surgical procedures if medical therapy fails 1

Required Physical Examination

• Perform digital rectal exam (DRE) to assess prostate size (approximate volume), consistency, shape, and rule out nodules suggestive of cancer 1
• Examine suprapubic area for bladder distention and assess perineal/lower limb motor and sensory function to rule out neurologic causes 1

Required Laboratory Tests

• Urinalysis with dipstick to identify hematuria, proteinuria, pyuria, or other pathology; obtain sediment examination and culture if abnormal 1
• Serum PSA measurement should be discussed with the patient regarding benefits/risks, and only obtained if life expectancy exceeds 10 years and a prostate cancer diagnosis would modify management 1

Treatment Algorithm Based on Initial Assessment

For Mild Symptoms (IPSS 0-7) or Non-Bothersome Symptoms

• Provide reassurance and watchful waiting with lifestyle modifications including fluid management (target ~1 liter/24 hours), timed voiding, and avoiding bladder irritants 1, 4
• Schedule follow-up monitoring without initiating pharmacotherapy 1

For Moderate-to-Severe Bothersome Symptoms (IPSS ≥8)

First-Line: Alpha-Blocker Monotherapy

• Initiate alpha-blocker as first-line therapy for patients with small prostates (<30cc) 1, 2
• Alpha-blockers improve symptoms within 2-4 weeks by relaxing smooth muscle in the prostate, bladder neck, and prostatic urethra 1, 5, 6
• Options include alfuzosin, tamsulosin (no titration needed, minimal blood pressure effects), terazosin, or doxazosin (once-daily dosing) 5, 7, 6
• Schedule first follow-up at 4-12 weeks after initiating alpha-blocker therapy 2, 3

Consider 5-Alpha Reductase Inhibitor Addition

• Add or consider 5-alpha reductase inhibitor (finasteride or dutasteride) when prostate volume exceeds 30cc to reduce prostate size, lower risk of acute urinary retention, and decrease need for surgery 1, 8, 7
• Finasteride requires 6 months to assess effectiveness and 12 months for maximum benefit, making it slower-acting than alpha-blockers 8, 7, 6
• Schedule first follow-up at 3-6 months when initiating 5-alpha reductase inhibitors due to delayed onset 2, 3

Combination Therapy

• Finasteride combined with alpha-blocker (doxazosin) reduces risk of symptomatic BPH progression (confirmed ≥4 point increase in AUA score) 8
• Combination therapy leverages the rapid symptom relief of alpha-blockers with the disease-modifying effects of 5-alpha reductase inhibitors 1, 6

Alternative for Concurrent Erectile Dysfunction

• Consider PDE5 inhibitor as initial therapy if patient also has erectile dysfunction, with first follow-up at 4-12 weeks 1, 2

Follow-Up Monitoring Protocol

• Readminister IPSS at every follow-up visit to objectively document symptom trajectory 2, 3
• Timing varies by medication class: 4-12 weeks for alpha-blockers/PDE5 inhibitors, 3-6 months for 5-alpha reductase inhibitors 2, 3
• Treatment decisions should be based on both IPSS score changes and the patient's bother level from the quality-of-life question 2, 3

Indications for Urologic Referral

• Refer for surgical evaluation when BPH-related complications develop (recurrent urinary retention, recurrent urinary tract infections, bladder stones, renal insufficiency from obstruction), medical therapy fails after adequate trial, or patient prefers surgical intervention 1, 9, 4
• Surgical options include TURP (most effective), transurethral incision for prostates <30g, or minimally invasive procedures 7

Critical Pitfalls to Avoid

• Do not rely on IPSS score alone—a moderately symptomatic but highly bothered patient may need intervention more urgently than a severely symptomatic but unbothered patient 2, 3
• Do not use finasteride in prostates <40cc—efficacy is prostate size-dependent and inadequate in smaller glands 7
• Do not assess finasteride response before 6 months—premature discontinuation prevents achieving therapeutic benefit 8, 7
• Do not ignore the sexual function history—this guides selection between alpha-blockers and PDE5 inhibitors 1
• Do not skip PSA counseling—discuss false-positive/negative risks and biopsy complications before ordering 1