Management of BPH
SUMMARY:
Benign prostatic hyperplasia (BPH) is a common medical condition that affects older men as smooth muscle and epithelial cells within the prostate proliferate with increasing age. Patients with BPH leading to benign prostate enlargement (BPE) can develop lower urinary tract symptoms (LUTS) that range from a mild impact on quality of life to severe and life-threatening urinary retention. Medical and surgical therapies are available to manage symptoms and ameliorate potential complications.
Evaluation
- BPH is common in older men and anyone with functioning testes
- Prevalence increases starting in a patient’s 40s and affects 80% of men by the age 80
- Not in men castrated before puberty or with atrophic prostate glands
- Not everyone with BPH will develop benign prostatic enlargement (BPE) or subsequent lower urinary tract symptoms
- Lower urinary tract symptoms (LUTS) include:
- Storage: Urgency | Frequency | Nocturia | Incontinence
- Voiding: Hesitancy | Slow stream | Dribbling | Straining | Dysuria
- Postmicturition: Incomplete emptying | Post urination dribbling
- Patients presenting with complaints of LUTS should undergo: Physical exam | Clinical history | Medication review | Urinalysis testing | International Prostate Symptom Score (IPSS) (see “Learn More” below)
- Patients treated for LUTS should have follow up within 4 to 12 weeks to reassess symptoms and response to therapy/modifications
- Repeat IPSS is helpful in assessing trend of symptom burden and BPH severity
Treatment
- Treatment for LUTS due to BPH and BPE should include shared decision-making discussing the main treatment options: Lifestyle/Behavior modification | Medical therapy | Surgical/Procedural therapy
Lifestyle Modifications
- Limit fluid intake, especially prior to bedtime or expected long periods away from a bathroom (e.g., Travel | Social gatherings)
- Avoid diuretics (e.g., Medications | Alcohol | Caffeine)
- Avoid constipation
- Maintain a healthy weight | Regular exercise
Medical Therapy
- Alpha blockers: Alfuzosin (Uroxatral) | Doxazosin (Cardura) | Silodosin (Rapaflo) | Tamsulosin (Flomax) | Terazosin (Hytrin)
- All have similar efficacy and can expect to improve IPSS scores by 5 to 8 points
- Treatment failure of one alpha blocker should not be followed by trial of a different alpha blocker
- Poorly tolerated side effects can be a reason to switch between different alpha blockers
- Non-specific alpha blockers can affect blood pressure (e.g., Doxazosin (Cardura) | Terazosin (Hytrin)) and their BP effects can be potentiated by concomitant PDE5 use
- Selective alpha blockers (e.g., Silodosin (Rapaflo) | Tamsulosin (Flomax) | Alfuzosin (Uroxatral)) have lower potential to cause orthostatic hypotension and syncope
- Alpha blockers increase risk of intraoperative floppy iris syndrome (IFIS) and should be held for 5 to 7 days before cataract surgery
- Alpha blockers should be initiated in any patient with acute urinary retention (AUR) prior to attempting a voiding trial for at least 3 days
- 5- Alpha Reductase inhibitor (5-ARI): Finasteride (Proscar) | Dutasteride (Avodart)
- Used in patients with one of the following: Prostate volume of > 30g | Prostate specific antigen (PSA) > 1.5ng/mL | Palpable prostate enlargement on digital rectal exam
- Can shrink the prostate by 15 to 25% after 6 months of treatment
- Patients should be counseled on expected time delay for symptom improvement if used as monotherapy
- If future prostate surgery is planned for treatment of BPE, use of 5-ARI in the months preceding may decrease bleeding in the peri- and post-operative period
- 5-ARIs may be helpful in treating refractory hematuria due to BPE
- Side effects may limit use and include: Sexual dysfunction | Gynecomastia
- Phosphodiesterase-5 Inhibitor (PDE5): Tadalafil (Cialis) | Sildenafil (Viagra)
- Tadalafil 5mg daily has been shown to improve LUTS symptoms in patients with BPH, even in the absence of erectile dysfunction
- Tadalafil 5mg had similar efficacy to Tamsulosin 0.4mg in improvement of IPSS
- Tadalafil is the only PDE5 that is FDA approved for LUTS, but studies have shown efficacy with Sildenafil as well
- Combination therapy
- For patients starting on a 5-ARI, the addition of an alpha blocker can help reduce LUTS symptoms in the first few weeks
- Clinicians may offer the combination of low-dose daily 5mg tadalafil with alpha blockers OR a 5-ARI for the treatment of LUTS
- Patients without clinical improvement over 4 weeks (following initiation of an alpha blocker or PDE5) or over 6 to 12 months (for patients started on 5-ARI) should be referred to a specialist to consider additional work up and treatment options
- Patients who have clinical improvement but develop intolerable medication-related side effects should also be referred to urology for consideration of surgical interventions
Surgical Therapy
- Prior to consideration of surgical interventions, patients should consider undergoing preoperative testing including
- Assessment of prostate size and shape (e.g., Transrectal or abdominal ultrasound | Cystoscopy | MRI | CT)
- Post-void residual (PVR): PVR >300 mL is considered large
- Uroflowmetry | Pressure flow studies
- Surgery should be offered to patients with complications due to their BPH/BPE including
- Renal insufficiency | Refractory urinary retention | Recurrent urinary tract infections | Recurrent bladder stones | Gross hematuria | BPH/LUTS refractory to other therapies | BPH/LUTS symptoms unwilling to trial other therapies
- Surgical options are plentiful and should be chosen based on patient characteristics and comorbid conditions, as well as operator expertise
- Transurethral Resection of the Prostate (TURP)
- Simple Prostatectomy
- Transurethral Incision of the Prostate (TUIP)
- Transurethral Vaporization of the Prostate (TUVP)
- Photoselective Vaporization of the Prostate (PVP)
- Prostatic Urethral Lift (PUL)
- Water Vapor Thermal Therapy (WVTT)
- Laser Enucleation
- Robotic Waterjet Treatment (RWT)
- Prostate Artery Embolization (PAE)
- Temporary Implanted Prostatic Devices (TIPD)
KEY POINTS:
- Benign prostatic hyperplasia is an exceedingly common medical condition in older men that can lead to prostate enlargement and the development of lower urinary tract symptoms
- Symptoms and signs of BPH can range for mild (e.g., Frequency | Slow stream) to severe (e.g., Hematuria | Renal insufficiency | Acute urinary retention)
- Treatment includes behavior and lifestyle modifications, as well as medical and/or surgical therapy
- Medical therapy is comprised of mono- or combination therapy with alpha blockers, 5-alpha reductase inhibitors, and phosphodiesterase-5 Inhibitors
- Surgical therapy should be offered to patients who fail to improve with medical therapy or have significant complications from their BPH
Primary Sources – Learn More
International Prostate Symptom Score (IPSS)
Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline
Association of 5α-Reductase Inhibitors With Prostate Cancer Mortality
Related PcMed Topics:

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