BPH Treatment & Management

TREATMENT

A. General Instruction

• Self-directed behavioral management program

B. Pharmacological

• Alpha-adrenergic blockers

C. Surgical

• Transurethral resection

A. GENERAL

• Self-directed behavioral management program

  • Limitation of fluids
  • Bladder training focused on timed and complete voiding
  • Treatment of constipation, which may help patients to regulate urinary symptoms.
  • Fluid avoidance after dinner, limitation of caffeinated beverages, and avoidance of diuretics

• Review of the patient’s medication list will help to identify opportunities to modify or avoid medications that may impact symptoms of BPH.

SPECIFIC TREATMENT

A. Pharmacological

1. Alpha-adrenergic blockers:
   • Terazosin, Doxazosin, Tamsulosin, Alfuzosin, Silodosin
2. 5 alpha-reductase inhibitors
   • Finasteride, Dutasteride
3. Phosphodiesterase type 5 inhibitor:
   • Tadalafil

B. Surgical

• Transurethral resection of the prostate or others

PHARMACOLOGICAL TREATMENT

• Alpha-adrenergic blockers:

  • For patients with mild to moderate obstructive symptoms, decreases voiding problems.

• 5 alpha-reductase inhibitors:

  • Reduces prostate size, decreasing voiding problems over months, especially in patients with larger (> 30 mL or even >40 mL) glands.

  • A combination of both classes of drugs is superior to monotherapy.

• Phosphodiesterase type 5 inhibitor:

  • For men with concomitant erectile dysfunction, daily tadalafil may help relieve both conditions.

SURGICAL TREATMENTY

Indications:

1. No response to drug therapy
2. Develop complications: 3. Recurrent UTI, Renal stones 4. Severe bladder dysfunction 5. Upper UTI

Transurethral resection of the prostate (TURP) is the standard.

• Erectile function and continence are usually retained, although about 5 to 10% of patients experience some postsurgical problems, most commonly retrograde ejaculation.

• The incidence of erectile dysfunction after TURP is between 1 and 35%. About 10% of men undergoing TURP need the procedure repeated within 10 years because the prostate continues to grow.

Surgical Techniques for the Treatment of Benign Prostatic HyperplasiaY

Technique	Setting	Cost	Comments
TURP	Inpatient	High initial cost may be offset by long-term durability of symptom relief	Common complications include hemorrhage, sexual dysfunction, strictures, and hyponatremia caused by absorption of the hypotonic irrigant; TURP is considered the benchmark for surgical therapies
Laser prostatectomy	Inpatient	High initial cost may be offset by long-term durability of symptom relief	Less perioperative morbidity and comparable clinical results after two years as TURP; steep learning curve for surgeons
Transurethral incision of the prostate	Outpatient or overnight hospitalization	Lower initial cost, but retreatment may be needed	Less risk of retrograde ejaculation than with TURP
Transurethral microwave therapy	Outpatient	Lower initial cost, but retreatment may be needed	No need for general anesthesia
Transurethral needle ablation	Outpatient	Lower initial cost, but retreatment may be needed	No need for general anesthesia

---

TURP = transurethral resection of the prostate.
Information from reference 6 and 24 through 30.

Other ProceduresY

• Alternatives to TURP include:
  • Microwave thermotherapy
  • Electrovaporization
  • Various laser techniques
  • High-intensity focused ultrasonography
  • Transurethral needle ablation
  • Radiofrequency vaporization
  • Pressurized heated water injection therapy
  • Urethral lift
  • Steam injection therapy
  • Intraurethral stents

Urinary Retention

• Significant urinary retention requires immediate decompression.
• Passage of a standard urinary catheter is first attempted.

COMPLICATIONS OF LONG STANDING BPH

1. Acute urinary retention
2. Recurrent UTI
3. Renal stones
4. Severe bladder dysfunction
5. Upper UTI

URGENT REFERRAL INDICATIONS

to UROLOGY

Clinical Indicators

1. Microscopic or macroscopic hematuria
2. Neurological disease (such as long-standing diabetes): may suggest neurogenic bladder
3. H/O prior urological surgeries and urethral stricture
4. History of recurrent infection
5. Palpable bladder
6. Renal impairment due to lower urinary tract dysfunction
7. Abnormal digital rectal exam suggesting prostate cancer
8. Abnormal PSA levels.

SUMMARY OF THE MANAGEMENT PLAN

Benign Prostatic Hyperplasia (BPH) Management Guidelines

Key Recommendations for Practice

Clinical Recommendations

• Men with suspected BPH can be evaluated with a validated questionnaire to quantify symptom severity.
• In men with symptoms of BPH, a digital rectal examination and urinalysis should be performed to screen for other urologic disorders.
• Watchful waiting with annual follow-up is appropriate for men with mild BPH.
• Alpha blockers provide symptomatic relief of moderate to severe BPH symptoms.
• In men with a prostate volume greater than 40 mL, 5-alpha reductase inhibitors should be considered for the treatment of BPH.
• Refer patients for a surgical consultation if:
  • Medical therapy fails.
  • The patient develops refractory urinary retention, persistent hematuria, or bladder stones.
  • The patient chooses primary surgical therapy.

---

BPH = benign prostatic hyperplasia.

Evidence Rating System:

• A = consistent, good-quality patient-oriented evidence
• B = inconsistent or limited-quality patient-oriented evidence
• C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series

For information about the SORT evidence rating system, see page 1360 or www.aafp.org/afpsort.xml.

Tables

Table 1: Differential Diagnosis of Lower Urinary Tract Symptoms in Men

Clinical Finding	Possible Diagnosis
Abnormal sphincter tone	Neurogenic bladder
Fever	Prostatitis
Hematuria	Bladder cancer
Prostate nodule or induration	Prostate cancer
Prostate tenderness	Prostatitis

Table 2: Medications and Medical Conditions That May Contribute to Lower Urinary Tract Symptoms in Men

Factor	Mechanism
Medications
- Antihistamines	Decreased parasympathetic tone
- Decongestants	Increased sphincter tone via alpha₁-adrenergic receptor stimulation
- Diuretics	Increased urine production
- Opiates	Impaired autonomic function
- Tricyclic antidepressants	Anticholinergic effects
Medical Conditions
- Bladder cancer	Mechanical obstruction
- Congestive heart failure	Diuresis
- Diabetes	Osmotic diuresis, autonomic neuropathy
- Parkinson’s disease	Autonomic neuropathy
- Prostate cancer	Mechanical obstruction