What is the recommended treatment approach for a male patient over 50 diagnosed with Benign Prostatic Hyperplasia (BPH)?

BPH Treatment Pathway

Initial Assessment and Risk Stratification

All men over 50 with suspected BPH should be evaluated using the International Prostate Symptom Score (IPSS/AUA Symptom Score) to categorize severity as mild (<7), moderate (8-19), or severe (≥20), and must assess whether symptoms are bothersome to the patient. 1, 2

• Measure serum PSA in patients with ≥10-year life expectancy to exclude prostate cancer and predict BPH progression risk 1, 3
• Perform digital rectal examination to assess prostate size, consistency, and exclude nodules suggesting malignancy 3
• Obtain urinalysis to exclude infection or hematuria 3
• Consider post-void residual (PVR) measurement and uroflowmetry for objective assessment 4, 3

Treatment Algorithm Based on Symptom Severity

Mild Symptoms (IPSS <7) or Non-Bothersome Symptoms

Watchful waiting is the standard approach regardless of symptom severity if the patient is not bothered, as treatment risks outweigh benefits in this population. 1, 2

• Schedule annual follow-up with repeat IPSS assessment 1, 2
• Counsel on lifestyle modifications 5

Moderate-to-Severe Bothersome Symptoms (IPSS 8-19 or ≥20)

Alpha-blockers are first-line therapy for all symptomatic patients, providing rapid symptom relief within 2-4 weeks regardless of prostate size. 1, 2

• Start tamsulosin 0.4 mg once daily (taken 30 minutes after the same meal daily), which can be increased to 0.8 mg after 2-4 weeks if inadequate response 6, 5
• Alternative alpha-blockers include alfuzosin, doxazosin, or terazosin 4, 7
• Reassess at 2-4 weeks using IPSS to objectively measure treatment response 1, 2

Patients with Enlarged Prostates (>30-40cc or PSA >1.5 ng/mL)

Add a 5-alpha reductase inhibitor (5-ARI) to the alpha-blocker for combination therapy, which addresses both dynamic and static components of obstruction and reduces risk of disease progression. 1, 2

• Start finasteride 5 mg daily or dutasteride 4, 8, 5
• Combination therapy (alpha-blocker plus 5-ARI) reduces overall risk of progression by 67%, acute urinary retention by 79%, and need for surgery by 67% 4
• The best-tested combination is doxazosin plus finasteride, though other alpha-blocker/5-ARI combinations are likely comparable 4
• Reassess at minimum 3-6 months for 5-ARI efficacy, with maximum benefit at 12 months 1, 2

Special Populations

For patients with erectile dysfunction, PDE5 inhibitors (tadalafil 5 mg daily) can be started as initial therapy instead of alpha-blockers. 1, 9

• Tadalafil improves both BPH symptoms and erectile function 5, 9
• PDE5 inhibitors combined with 5-ARIs reduce LUTS more substantially than 5-ARI alone and reduce sexual side effects during 5-ARI treatment 9

For patients with predominant storage symptoms (urgency, frequency) and small prostates, consider antimuscarinic agents after excluding bladder outlet obstruction. 4, 10

• Combination of alpha-blocker plus antimuscarinic is more efficacious than either alone 4, 9
• Ensure adequate bladder emptying before initiating antimuscarinics 4

Follow-Up Strategy

• Alpha-blockers, PDE5 inhibitors, and antimuscarinics: First follow-up at 4 weeks 1
• 5-ARIs: First assessment at 3-6 months 1, 2
• Stable patients: Annual follow-up repeating initial evaluation to detect symptom progression or complications 4, 1
• Monitor for orthostatic hypotension and dizziness with alpha-blockers 2
• Counsel patients on potential sexual side effects of 5-ARIs (decreased libido, erectile dysfunction, decreased ejaculate volume, ejaculatory disorders) 8, 11

Absolute Indications for Urological Referral

Patients must be referred to urology immediately if they develop any of the following complications: 1, 2

• Refractory urinary retention
• Recurrent urinary tract infections
• Recurrent gross hematuria
• Bladder stones
• Renal insufficiency due to BPH
• Upper tract dilatation with hydronephrosis
• Large post-void residual volumes (>300-350 mL)

Surgical Intervention

Transurethral resection of the prostate (TURP) remains the gold standard surgical approach for patients who fail medical therapy or have absolute indications for surgery. 4, 1, 3

• Consider surgical referral for patients with persistent bothersome symptoms despite maximal medical therapy 4, 2
• Pressure-flow studies are indicated if Qmax >10 mL/second to confirm obstruction before surgery, as treatment failure rates are higher without documented obstruction 4
• Alternative minimally invasive procedures may be discussed when available 4, 7

Critical Pitfalls to Avoid

• Do not treat patients with non-bothersome symptoms regardless of severity—treatment risks outweigh benefits 1, 2
• Do not delay evidence-based medical therapy, as this allows disease progression and potential complications including acute urinary retention 2
• Do not assess 5-ARI efficacy before 3 months—finasteride requires 6 months for full assessment and 12 months for maximum prostate shrinkage 4, 7
• Do not use 5-ARIs in patients with prostate volume <30-40 mL—efficacy is dependent on prostate size 2, 7
• Counsel patients about sexual adverse effects before initiating therapy, as counseling itself influences reported rates of sexual dysfunction 11
• Be aware that the incidence of Gleason score 8-10 prostate cancer was higher (1.8% vs 1.0%) in men treated with finasteride in the PCPT trial 8