Benign Prostatic Hyperplasia (BPH)

Diagnose BPH:

  • Medical history:
    • Irritative Sx: urinary urgency, frequency, and nocturia
    • Obstructive Sx: decreased urinary stream, intermittency, incomplete emptying of bladder, straining to urinate
  • Digital rectal examination

Manage BPH:

  • Goals of treating BPH: Reduce symptoms and improve quality of life.
    • Mild symptoms:
      • Conservative measures and observation.
        • Ex: Reduce fluid intake, timed voiding (q3hrs while awake), limiting caffeine/alcohol (diuretics), modifying medications (avoid/stop diuretics and anticholinergics – promote urinary retention), improve mobility (easy walk to bathroom PRN), and avoid bladder irritants.
    • Moderate-to-severe symptoms:
      • Conservative measures and observation.
        • Ex: Reduce fluid intake, timed voiding (q3hrs while awake), limiting caffeine/alcohol (diuretics), modifying medications (avoid anticholinergics), improve mobility (easy walk to bathroom PRN), and avoid bladder irritants.
      • Medical treatment: (if Sx do NOT respond to conservative measures)
      • Alpha blockers are superior to 5-alpha reductase inhibitors.
      • Combination of alpha blocker (Flomax) with 5 alpha-reductase inhibitor (Finasteride) is more effective than either drug alone but has more side effects.
        • ***1st line: Alpha-blockers = relax smooth muscles in the urethral and bladder neck -> improves urine flow. All are equally effective in Tx BPH but differ in tolerability and cardiovascular
          • Side effects: Headache, dizzy, nasal congestion, hypotension, edema, palpitations, fatigue, ED
            • More likely to cause hypotension:
              • Doxazosin, Terazosin, Alfuzosin, Prazosin
            • Less likely to cause hypotension:
              • Tamsulosin (Flomax), Silodosin
        • PDE-5 inhibitor: Tadalafil
          • Tx combination of BPH with ED
          • Caution: Combination of PDE-5 inhibitors with alpha-blockers can cause hypotension.
        • 5 alpha – Reductase inhibitors:
          • Inhibit the conversion of testosterone -> 5 alpha – dihydrotestosterone.
          • Reduces prostate size and growth (less available testosterone) gradually.
            • Therapeutic effect may take several months to appreciate.
            • Side effects (low testosterone): ED and decreased libido
          • Ex: Finasteride (Proscar), Dutasteride
          • Most effective in men with BPH who have LARGE prostates (>40ml), moderate-to-severe Sx, and elevated PSA levels. (combine with alpha blocker)
            • Decrease PSA levels significantly, so to determine accurate PSA level of man on med: multiple the PSA value by 2 in patients taking 5-ARIs who require PSA testing.
            • Of note: PSA can be elevated secondary to BPH by itself.
      • Invasive interventional therapy:
        • Indicated in patients with severe urinary symptoms, urinary retention, persistent hematuria, recurrent UTIs, or renal insufficiency clearly attributable to BPH.
          • Transurethral resection of the prostate (TURP)
          • Transurethral needle ablation (TUNA)

Refer to Urology:

  • Severe Sx refractory to medical therapy
  • Acute urinary retention
  • Bladder stones
  • Persistent gross hematuria
  • Recurrent UTIs
  • Obstructive nephropathy

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