Blood Pressure Management and Benign Prostatic Hyperplasia

Monitoring and Assessment

• The American College of Cardiology recommends monitoring for orthostatic hypotension, especially in older adults 1
• The International Prostate Symptom Score (IPSS) should be used to quantify the severity of lower urinary tract symptoms (LUTS) in patients with Benign Prostatic Hyperplasia (BPH) 2
• A quality of life assessment related to urinary symptoms should be performed in patients with BPH 2
• A digital rectal examination should be performed to confirm prostatic enlargement in patients with BPH 3
• A focused neurological examination should be conducted to assess for other causes of LUTS in patients with BPH 3
• Urinalysis should be performed to rule out infection and hematuria in patients with BPH 2, 3
• PSA measurement should be considered if life expectancy is >10 years or if it would change management in patients with BPH 3
• Serum creatinine should be measured if renal insufficiency is suspected in patients with BPH 3
• Post-void residual (PVR) measurement and uroflowmetry should be performed to assess the severity of obstruction in patients with BPH 4
• Pressure-flow studies should be considered if surgery is being considered and obstruction is not clearly evident in patients with BPH 4

Treatment

• Alpha blockers should be used as first-line therapy for rapid symptom relief in patients with BPH 2
• 5-alpha reductase inhibitors (5ARIs) should be added for patients with a prostate size >30cc 2
• Combination therapy (alpha blocker + 5ARI) is particularly appropriate for patients with large prostate and median lobe hypertrophy 2
• The following table summarizes the efficacy of 5-ARIs:

• Beta-3-agonists, such as mirabegron, may be offered as a treatment option to patients with moderate to severe predominate storage LUTS, in combination with an alpha blocker, as suggested by the AUA guidelines and studies like MATCH and PLUS 2, 5
• Anticholinergic agents, alone or in combination with an alpha blocker, may be offered as a treatment option to patients with moderate to severe predominant storage LUTS, according to the AUA guidelines 2
• Phosphodiesterase-5 (PDE-5) inhibitors, such as tadalafil 5mg daily, can improve BPH symptoms, particularly for patients with concomitant erectile dysfunction, but should not be combined with alpha blockers, as recommended by the AUA guidelines 2, 3

Surgical Treatment

• The American Urological Association indicates that surgical treatment is recommended for patients with BPH who have failed medical therapy, recurrent urinary retention, recurrent UTIs, renal insufficiency, recurrent gross hematuria, or bladder stones due to BPH 6
• Transurethral Resection of the Prostate (TURP) is considered the gold standard surgical treatment, but has a higher risk of bleeding compared to newer modalities 6
• Laser Enucleation, including Holmium laser enucleation (HoLEP) or thulium laser enucleation (ThuLEP), is suitable for all prostate sizes and has better coagulative properties than TURP, making it recommended for patients on anticoagulation therapy 6
• Photoselective Vaporization of the Prostate (PVP) is a safe option for patients on anticoagulation, but may require longer catheterization and irrigation 6
• Water Vapor Thermal Therapy is suitable for prostates <80g, preserves erectile and ejaculatory function, but has limited long-term efficacy data 6

Follow-up and Monitoring

• Regular monitoring of sexual function, including erectile function and ejaculatory function, is recommended when treating BPH, particularly with 5ARIs, with a strength of evidence level of moderate, according to the American Urological Association 3
• PSA monitoring is also recommended, as 5ARIs reduce PSA by approximately 50% after 12 months, and a new baseline should be established after 3-6 months of treatment, with a strength of evidence level of high, according to the American Urological Association
• Lifestyle modifications, such as limiting evening fluid intake, reducing caffeine and alcohol consumption, and avoiding medications that worsen symptoms (decongestants, antihistamines), are recommended to manage BPH symptoms, with a strength of evidence level of low, according to the American Urological Association
• Patients should be counseled on lifestyle modifications, including rising slowly from sitting or lying positions, taking medication at bedtime, limiting evening fluid intake, reducing caffeine and alcohol consumption, and avoiding medications that can worsen symptoms (decongestants, antihistamines), as recommended by the AUA guidelines 2
• Pelvic floor exercises (Kegel exercises) combined with urethral milking technique can help manage post-void dribbling in patients taking tamsulosin for BPH treatment, as recommended by the AUA guidelines with a strength of evidence: Grade A 2
• Response to therapy should be evaluated within 4-12 weeks after initiating treatment 2, 4
• IPSS score should be reassessed, and PVR and uroflowmetry should be considered during follow-up 2, 4
• Annual follow-up is recommended if treatment is successful 4
• Patients should be monitored for complications, including acute urinary retention, recurrent UTIs, bladder stones, and renal insufficiency 2, 6
• Regular monitoring of post-void residual volume is important to detect early signs of urinary retention, as recommended by the AUA guidelines 2, 5, 3

Considerations and Precautions

• When selecting BPH treatment, it is essential to consider erectile function, as some treatments, such as 5ARIs, may cause sexual side effects, with a strength of evidence level of moderate, according to the American Urological Association 3
• Combining tadalafil with alpha blockers is not recommended due to the risk of hypotension, with a strength of evidence level of high, according to the American Urological Association
• Using 5ARIs in patients without prostate enlargement is ineffective, with a strength of evidence level of high, according to the American Urological Association 3
• Neglecting to establish a new PSA baseline after starting 5ARI therapy can lead to inaccurate monitoring of prostate health, with a strength of evidence level of moderate, according to the American Urological Association
• Overlooking the progressive nature of BPH in men with larger glands who may benefit from early intervention with 5ARIs despite sexual side effects can result in delayed treatment, with a strength of evidence level of moderate, according to the American Urological Association 3