What is the diagnosis and recommended treatment?

Diagnosis: Benign Prostatic Hyperplasia (BPH)

Based on the clinical presentation of lower urinary tract symptoms (LUTS) in a man over age 50, this is most consistent with benign prostatic hyperplasia, which requires a systematic diagnostic evaluation followed by treatment selection based on symptom severity and patient bother.

Diagnostic Evaluation

Recommended Initial Tests

The following diagnostic tests should be performed for all patients with suspected BPH 1:

• Medical history assessment including severity and duration of LUTS, impact on quality of life, history of urinary tract infections, hematuria, prior lower urinary tract procedures, and family history of prostate disease 1

• AUA Symptom Score to quantify symptom severity (score 0-35, with ≥8 indicating moderate to severe symptoms) 1

• Physical examination including digital rectal examination (DRE) to assess prostate size and exclude locally advanced prostate cancer, plus focused neurologic examination assessing mental status, ambulatory status, lower extremity neuromuscular function, and anal sphincter tone 1

• Urinalysis by dipstick or microscopic examination to screen for hematuria and urinary tract infection 1

• Post-void residual (PVR) volume measurement using bladder scanner or catheterization 2

Optional Tests in Select Patients

• Serum PSA measurement is recommended in select patients, particularly those with life expectancy >10 years where prostate cancer detection would change management 1

• Urine cytology is optional in men with predominantly irritative symptoms to exclude bladder pathology 1

• Voiding diaries may be helpful in selected patients, especially those with nocturia as the predominant symptom 1

Tests NOT Routinely Recommended

• Cystoscopy should only be performed if Hunner lesions or other bladder pathology is suspected, not for routine BPH diagnosis 1

• Urodynamic studies are not recommended for routine clinical use to establish BPH diagnosis 1

Treatment Algorithm

For Mild Symptoms (AUA Score <7) or Non-Bothersome Symptoms

Standard recommendation: Watchful waiting is the appropriate management strategy 1

This applies even to patients with moderate to severe symptom scores if they report the symptoms do not interfere with daily activities 1.

For Bothersome Moderate to Severe Symptoms (AUA Score ≥8)

Treatment options should be discussed with the patient, including benefits, harms, adverse effects, cost, and feasibility 1. The following represents a hierarchical approach:

First-Line Treatment Options

Option 1: Monotherapy with alpha-adrenergic blockers 1

• Alfuzosin, doxazosin, tamsulosin, or terazosin
• Provides rapid symptom relief
• Does not reduce prostate size or prevent disease progression

Option 2: Monotherapy with 5-alpha-reductase inhibitors 1

• Dutasteride or finasteride
• Reduces prostate size over time (requires 6-12 months for maximal effect)
• Most effective in men with larger prostates (>40g)
• Prevents disease progression and reduces risk of acute urinary retention

Option 3: Combination therapy 1

• Alpha-blocker plus 5-alpha-reductase inhibitor
• Best-tested combination is doxazosin plus finasteride
• Provides both immediate symptom relief and long-term disease modification

Option 4: Watchful waiting 1

• Remains appropriate even for moderate to severe symptoms if patient prefers after informed discussion

Minimally Invasive Therapies

These are options for patients who prefer intervention but wish to avoid surgery 1:

• Transurethral microwave heat treatments (CoreTherm, Prostatron, Targis, TherMatrx)
• Transurethral needle ablation (TUNA)
• UroLume stent (only for specific subset of patients)

Important caveat: The following require additional data before routine recommendation: interstitial laser coagulation, water-induced thermotherapy, PlasmaKinetic Tissue Management System 1. These should only be offered with explicit discussion of uncertainty compared to established options 1.

Surgical Therapies

Reserved for patients with refractory symptoms, complications, or patient preference 1:

• Transurethral resection of the prostate (TURP) - gold standard surgical treatment
• Transurethral electrovaporization
• Transurethral incision of the prostate
• Transurethral holmium laser resection/enucleation
• Transurethral laser vaporization
• Transurethral laser coagulation
• Open prostatectomy (for very large prostates)

For Patients with Complications

Surgery remains the treatment of choice for patients with urinary retention or other serious BPH complications, assuming acceptable surgical risk 1.

Critical Management Principles

• Treatment efficacy should be periodically reassessed, and ineffective treatments should be stopped 1

• Patient education is essential: Inform patients that BPH is typically chronic, requiring continual management; acceptable symptom control may require trials of multiple therapeutic options; and the typical course involves symptom exacerbations and remissions 1

• Behavioral modifications should be discussed, including fluid management, avoidance of bladder irritants, and timed voiding strategies 1

Common Pitfalls to Avoid

• Do not perform cystoscopy routinely on every BPH patient - the risk/benefit ratio is unfavorable, particularly in younger patients with low prevalence of Hunner lesions 1

• Do not use balloon dilation - this is not recommended as a treatment option due to high failure rates over time 1

• Do not recommend phytotherapeutic agents or dietary supplements - insufficient evidence supports their use 1

• Do not offer high-intensity focused ultrasound or absolute ethanol injection outside clinical trials 1

• Recognize that men with polyuria, underlying neurologic disease, prior lower urinary tract disease, or younger men with voiding dysfunction require more extensive evaluation beyond standard BPH workup 1