Elder Care Interprofessional Provider Sheets

Benign Prostatic Hyperplasia

Jonathan Edwards, MD, Colleges of Medicine and Pharmacy, Northeastern Ohio Universities

October 2018

TIPS FOR DEALING WITH BENIGN PROSTATIC HYPERPLASIA 
  • Evaluate symptom severity with the American Urological Association Symptom Index. 
  • Prescribe alpha-blockers as the usual initial approach to medical therapy. Selective agents are best for older men at risk for orthostatic hypotension.
  • Prescribe 5-alpha reductase inhibitors only to men with a grossly enlarged prostate gland (volume >40 ml or prostate specific antigen level >1.4ng/ml). 
  • Recommend surgical therapy for men who develop urinary obstruction, and consider surgical therapy for men whose symptoms do not respond to medical therapy.

Benign prostatic hyperplasia (BPH) refers to progressive enlargement of the prostate gland commonly seen in older men. Because the urethra passes through the prostate gland, BPH causes compression of the urethra and obstruction of urinary flow. Chronic urinary obstruction can also lead to increased irritability of the detrusor muscle. As a result of these abnormalities, men affected by BPH may complain of difficulty initiating urination, incomplete bladder emptying, urinary urgency, weak urinary stream, dribbling, or nocturia. One prevalence survey found that 42% of men over 50 years old had symptoms, although only one third of these intended to seek treatment.

For those who seek treatment, management is based on the presence and severity of symptoms. Symptom severity is usually assessed with the American Urological Association Symptom Index, a validated questionnaire readily available online. Patients with mild symptoms may not require treatment, while those with moderate to severe symptoms may benefit from medical or surgical therapy. Medical therapy is usually the initial approach.

Medical Therapy

Alpha-Blockers 

Alpha-blocking agents (Table 1) facilitate bladder emptying by relaxing the urethral sphincter. Non-selective alpha blockers also promote relaxation of vascular smooth muscle, lowering blood pressure, while selective alpha blockers have no effect on resting blood pressure. Multiple randomized trials have shown improved symptom control with alpha blockers compared to placebo.

Clinical benefit is usually apparent after two to four weeks of treatment. Despite their benefit for symptom control, alpha blockers do not appear to affect the underlying disease process. There is no evidence that these medications reduce the risk of urinary retention or the need for surgical intervention.

Orthostatic hypotension is a common side effect of all alpha blockers. The risk is increased if they are used in combination with medications for erectile dysfunction; in this circumstance, a low starting dose and cautious titration are critical.

Table 1. Medical Therapy for Benign Prostatic Hyperplasia
Medication Category Typical Dose
Alfuzosin Nonselective alpha blocker 10 mg daily
Doxazosin Nonselective alpha blocker 1 to 8 mg daily
Prazosin
Nonselective alpha blocker
2 to 15 mg daily, divided bid or tid
Terazosin Nonselective alpha blocker 1 to 20 mg daily
Silodosin Selective alpha blocker 8 mg daily
Tamsulosin Selective alpha blocker 0.4 to 0.8 mg daily
Dutasteride 5-α reductase inhibitor 0.5 mg daily
Finasteride 5-α reductase inhibitor 5 mg daily
Tadalafil Phosphodiesterase inhibitor 5 mg daily
Tolterodine Anticholinergic * 4 mg daily

*Not generally recommended for treatment of older adults

5-Alpha Reductase Inhibitors 

Prostate growth is stimulated by androgenic hormones, especially dihydrotestosterone. Inhibitors of the 5-alpha reductase enzyme (Table 1) block the conversion of testosterone to dihydrotestosterone, causing a reduction in prostate size. These medications have also been shown to improve symptom control over time, but six months of treatment is often necessary before a benefit is observed. They are only effective in men with marked enlargement of the prostate. Patients with a prostate volume of at least 40 mL (normal, 20-30 mL) or a PSA level of at least 1.4 ng/ mL are good candidates for 5-alpha reductase inhibitors. In contrast to alpha blockers, 5-alpha reductase inhibitors have been shown to reduce the risk of urinary retention and surgical intervention. Decreased libido and sexual dysfunction are common side effects.

Other medical therapies

The phosphodiesterase inhibitor tadalafil is approved by the FDA for treatment of both erectile dysfunction and symptoms of BPH. This drug may be a good choice for men with both conditions.  

Anticholinergic medications such as tolterodine are not specifically approved for BPH, but there is some evidence of benefit for the "irritative" symptoms of BPH (urinary urgency and frequency).  As a result, they are sometimes used for treatment. These agents may increase the risk of urinary retention in men with a post-void residual >250mL.  In addition, the American Geriatrics Society's most recent Beers criteria recommend against using these anticholinergic drugs in older men because of their potential to cause cognitive impairment. 

Surgical Therapy  

Surgery is warranted for men with refractory symptoms, urinary retention, or other complications such as bladder stones or recurrent urinary tract infections. The gold-standard surgical procedure is transurethral resection of the prostate (TURP), which usually provides long-term symptom control. TURP is an inpatient surgical procedure. Hemorrhage, retrograde ejaculation, erectile dysfunction, and urinary incontinence are potential complications.

Several newer surgical procedures (Table 2) are intended to avoid the morbidity associated with TURP. Depending on prostate size, a patient may be a candidate for several minimally invasive office procedures; however, most of these procedures provide less durable relief than TURP, and retreatment is often necessary. Holmium laser enucleation of the prostate has less perioperative morbidity than TURP with comparable symptom control for at least two years.                                                                                                                                                                          

Table 2. Surgical Therapy for Benign Prostatic Hyperplasia
Procedure Maximum Prostate Size General Anesthesia Required
TURP No limit YES
Holmium laser enucleation No limit YES
"Green light" KTP laser No limit NO
Transurethral incision of prostate 30 mL NO
Transurethral microwave therapy 100 mL NO

References and Resources

  • Foster HE, Barry MJ, Dahm P, et al. Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA guideline. J Urol 2018 (e-pub ahead of print).
  • Unnikrishnan R, Almassi N, Fareed K. Benign prostatic hyperplasia: Evaluation and medical management in primary care. Clev Clin J Med. 2017;84(1):53-64.