What is the approach to management of Benign Prostatic Hyperplasia (BPH)?

From the Guidelines

The approach to management of Benign Prostatic Hyperplasia (BPH) involves a multi-faceted approach, with the initial step being watchful waiting for patients with mild symptoms or moderate to severe symptoms without bother, as recommended by the American Urological Association (AUA) guideline 1. The management strategy should be based on the severity of symptoms, the degree of bother, and the presence of complications.

• For patients with mild symptoms (AUA Symptom Score <7) or moderate to severe symptoms without bother, watchful waiting is recommended, as the risks of medical therapy outweigh the benefits of symptom improvement in this group of men 1.
• For patients with bothersome moderate to severe symptoms, treatment options include medical therapies, such as alpha-blockers and 5 alpha-reductase inhibitors, minimally invasive therapies, and surgical therapies 1.
• The choice of treatment should be based on the patient's preferences, the severity of symptoms, and the presence of complications, with the goal of improving symptoms, preventing disease progression, and improving quality of life.
• The use of 5 alpha-reductase inhibitors, such as finasteride and dutasteride, is recommended for patients with symptomatic prostatic enlargement, as they have been shown to reduce the risk of acute urinary retention and the need for BPH-related surgery 1.
• Alpha-blockers, such as tamsulosin and alfuzosin, are also effective in improving symptoms, but may have a higher risk of adverse events, such as hypotension and ejaculatory dysfunction 1.
• Minimally invasive therapies, such as transurethral microwave heat treatments and transurethral needle ablation, may be considered for patients who are not candidates for medical therapy or who have failed medical therapy 1.
• Surgical therapies, such as transurethral resection of the prostate and open prostatectomy, are typically reserved for patients with severe symptoms or complications, such as urinary retention or renal insufficiency 1. Overall, the management of BPH requires a comprehensive approach, taking into account the patient's individual needs and preferences, with the goal of improving symptoms, preventing disease progression, and improving quality of life.

From the FDA Drug Label

1.1 Monotherapy Finasteride tablets are indicated for the treatment of symptomatic benign prostatic hyperplasia (BPH) in men with an enlarged prostate to:

• Improve symptoms
• Reduce the risk of acute urinary retention
• Reduce the risk of the need for surgery including transurethral resection of the prostate (TURP) and prostatectomy.

1.2 Combination with Alpha-Blocker Finasteride tablets administered in combination with the alpha-blocker doxazosin is indicated to reduce the risk of symptomatic progression of BPH (a confirmed ≥ 4 point increase in American Urological Association (AUA) symptom score).

The approach to management of Benign Prostatic Hyperplasia (BPH), also referred to as BO (likely a typo), involves:

• Monotherapy with finasteride to improve symptoms, reduce the risk of acute urinary retention, and reduce the need for surgery.
• Combination therapy with finasteride and an alpha-blocker (doxazosin) to reduce the risk of symptomatic progression of BPH 2. Alternatively, tamsulosin can be used as a treatment option, with a recommended dose of 0.4 mg once daily, which can be increased to 0.8 mg once daily if necessary 3.

From the Research

Approach to Management of Benign Prostatic Hyperplasia (BPH)

The management of BPH involves a combination of lifestyle modifications, medications, and surgery. The approach to management can be summarized as follows:

• Lifestyle modifications: Patients with mild or non-bothersome symptoms may not require treatment, but lifestyle modifications such as avoiding caffeine and alcohol, and managing fluid intake can help alleviate symptoms 4.
• Medical therapy: Alpha blockers are first-line medications for BPH, and 5-alpha reductase inhibitors can be used to reduce prostate size and prevent disease progression 5, 4, 6, 7, 8.
• Combination therapy: Combination therapy using alpha-1 adrenergic receptor antagonists and 5-alpha reductase inhibitors has been shown to be effective in managing BPH-related lower urinary tract symptoms and improving quality of life 6, 7.
• Surgical referral: Surgical referral is indicated if BPH-related complications develop, medical therapy fails, or the patient chooses it 4.

Treatment Options

The following treatment options are available for BPH:

• Alpha blockers: Alpha blockers such as terazosin, doxazosin, and tamsulosin can be used to manage BPH-related lower urinary tract symptoms 5, 4, 7, 8.
• 5-alpha reductase inhibitors: 5-alpha reductase inhibitors such as finasteride and dutasteride can be used to reduce prostate size and prevent disease progression 5, 6, 7, 8.
• Phosphodiesterase-5 inhibitors: Phosphodiesterase-5 inhibitors such as sildenafil can be used to manage BPH-related erectile dysfunction 8.
• Beta-3 agonists: Beta-3 agonists such as mirabegron can be used to manage BPH-related overactive bladder symptoms 8.
• Surgical procedures: Surgical procedures such as transurethral resection of the prostate (TURP) and open prostatectomy can be used to manage BPH-related complications 5, 4.