BPH Treatment

Watchful waiting

Medical therapy

Combination therapy

dicated as sole therapy in patients with mildly symptomatic BPH or as supplemental therapy in patients requiring medical therapy

Restrict fluid intake before bedtime or before going out.

Avoid/reduce caffeine and alcohol intake --> Caffeine and alcohol are diuretics.

Ensure complete bladder --> Micturating in the sitting position and double voiding

Mild BPH

Uncomplicated moderate BPH with minimal discomfort due to symptoms

Alpha-blockers (first-line)

Examples: tamsulosin, doxazosin, terazosin, alfuzosin

Mechanism of action: α1 receptors (α1A receptors) inhibition of the bladder neck and the prostatic urethra → relaxation of the smooth muscle of the bladder neck and the urethra → decreased resistance to urinary outflow → symptomatic improvement

α-blockers do not stop/decrease prostatic hyperplasia. They are primarily used for symptom control.

5-alpha-reductase inhibitors

Parasympatholytics/anticholinergics

Phosphodiesterase type 5 inhibitors

finasteride, dutasteride

↓ conversion of testosterone to DHT → lower intraprostatic DHT levels → decreased prostatic growth and increased prostatic apoptosis and involution → improvement of LUTS

Additional indications: androgenetic alopecia in males

Adverse effects: sexual dysfunction (erectile dysfunction, decreased libido, ejaculatory dysfunction), gynecomastia

Examples: oxybutynin, darifenacin

Indications: patients with irritative symptoms without an elevated post-void residual volume

Example: tadalafil /the only phosphodiesterase-5 inhibitor approved by the FDA for the management of BPH)

Indications: patients with mild/moderate BPH symptoms and erectile dysfunction

Severe symptoms of BPH

Inadequate response to medical monotherapy

alpha-blockers and 5-alpha-reductase inhibitor

alpha-blockers and anticholinergics

Severe BPH symptoms with/without complications

Moderate BPH with complications

Transurethral resection of the prostate (TURP)

Transurethral incision of the prostate (TUIP)

Open/laparoscopic/robotic prostatectomy

resection of the hyperplastic prostatic tissue under cystoscopic guidance, using a cautery resectoscope

The bladder is first distended with a solution which cannot conduct the cautery current (glycine, sorbitol, mannitol). Using a monopolar cautery resectoscope, the prostate is resected in slices until the entire hyperplastic tissue is removed. The prostatic capsule is left intact. The open post-resection cavity will re-epithelialize within 3 months

Retrograde ejaculation: most common complication (∼ 75% of patients) --> The bladder sphincter is partially resected during TURP → weakening of the bladder outlet → impaired closure of the bladder neck at ejaculation → retrograde ejaculation

TUR-syndrome

Urinary incontinence

Erectile dysfunction (∼ 10%): may be temporary or permanent

Urethral strictures (∼ 10%)

Recurrent BPH: ∼ 15% of men need to have a TURP again within 10 years.

dilutional hypotonic hyponatremia due to the absorption of the irrigant by the open prostatic blood vessels

TUR-syndrome is rare (< 1%) and occurs when an irrigant other than saline is used. If untreated, patients can develop severe consequences like cerebral/bronchial edema. Newer techniques use bipolar cautery, in which saline can be used as an irrigant.

indicated in patients with small prostates with obstructive symptoms or those at high risk for surgical complications

A deep incision is made through the prostatic urethra into the prostate, thus widening the bladder neck. Prostatic tissue is not resected.

Indicated in patients with very large prostates (> 75 g)

Freyer transvesical prostatectomy (enucleation of the prostate through the anterior wall of the bladder )

Retropubic prostatectomy

Perineal prostatectomy

Laser ablation, radiofrequency ablation, and microwave thermotherapy are the newest techniques used for prostate tissue resection.