Treatment for Benign Prostatic Hyperplasia

Initial Assessment and Stratification

The American Urological Association recommends alpha-blockers as the first-line medical therapy for patients with bothersome moderate to severe BPH symptoms (AUA Symptom Score >8), due to their superior symptom relief (4-6 point improvement in AUA Symptom Index) compared to 5-alpha-reductase inhibitors (3-point improvement), with faster onset of action 1, 2, 3
Watchful waiting is appropriate for patients with moderate to severe symptoms who are not bothered enough to pursue active treatment, and these patients should be monitored yearly with repeat evaluations and implement lifestyle modifications (reduce evening fluid intake, limit caffeine and alcohol) 1, 4
Medical therapy should be offered when AUA Symptom Score >8 with bothersome symptoms, and patients must be counseled on benefits and harms of all treatment options before initiating therapy 1, 3

Alpha-blocker monotherapy is recommended as the first-line treatment, with available agents including alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin, which are similarly effective (4-6 point IPSS improvement) but differ in adverse effect profiles 1, 3, 5, 6
Tamsulosin and silodosin have a lower risk of orthostatic hypotension but higher risk of ejaculatory dysfunction, while doxazosin and terazosin require dose titration and have a higher risk of orthostatic hypotension and dizziness 5, 6
Alfuzosin has an intermediate profile, and alpha-blockers should not be assumed to constitute optimal hypertension management, especially in men with hypertension and cardiac risk factors 1, 2, 5, 6
For patients planning cataract surgery, inform about intraoperative floppy iris syndrome (IFIS) risk and consider delaying alpha-blocker initiation until after surgery 3

5-ARI monotherapy is recommended when prostate enlargement is documented, with available agents including finasteride 5 mg daily or dutasteride, which have similar efficacy and safety profiles 2, 3, 6
5-ARIs are less effective than alpha-blockers for symptom improvement (3-point vs 4-6 point IPSS improvement), require 6 months to assess effectiveness, and have a major advantage of reducing risk of acute urinary retention and need for BPH-related surgery 2, 3, 6
Adverse effects of 5-ARIs include sexual dysfunction, decreased PSA by approximately 50%, and a potential increased risk of Gleason 8-10 prostate cancer 2, 3, 6

Combination therapy is indicated to reduce risk of symptomatic BPH progression and further reduce risk of urinary retention and need for surgery beyond either monotherapy 3, 4
The best-studied combination is doxazosin plus finasteride, which has additive adverse effects, including higher incidence of asthenia, postural hypotension, peripheral edema, dizziness, and sexual dysfunction compared to monotherapy 1, 2, 4

Minimally invasive therapies, such as transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA), are considered when medical therapy fails or is not tolerated, and have efficacy that lies between TURP and medical therapy 1, 4

TURP remains the benchmark surgical therapy with strongest long-term efficacy data from randomized trials, and indications for surgical referral include moderate-to-severe LUTS refractory to medical therapy, intolerable drug-related side effects, and complications of BPH 1, 3, 4
Surgical options include TURP, transurethral incision of the prostate (TUIP), transurethral electrovaporization, laser procedures, and open prostatectomy, each with its own set of complications and considerations 1, 4

Monitor treatment response using IPSS scores and Global Subjective Assessment (GSA), and continue therapy if patient reports improvement matching IPSS improvement, or reassess and discuss alternative treatments if patient reports neutral/worsening response despite stable/improved IPSS 3