Benign Prostatic Hyperplasia

Page updated Winter 2021.
Disclaimer: Medicine is an ever-changing science.  We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable resources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original resources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.

Medical Treatment of Benign Prostatic Hyperplasia- BPH

α1-blockers 

Will be offered to men to with moderate-to-severe lower urinary tract symptoms (LUTS).

Currently available medications are: tamsulosin, silodosin, terazosin, doxazosin, and alfuzosin.

5α-reductase inhibitors

Will be offered to men to with moderate-to-severe LUTS and a prostate volume > 40 mL.

Onset of action will be delayed for three to six months.

Currently available medications are: finasteride and dutasteride.

Muscarinic receptor antagonists

Will be offered to men with moderate-to-severe LUTS who mainly have bladder storage symptoms.

Will not be offered if post-void residual volume > 150 mL.

Currently available medications are:
oxybutynin, tolterodine,  fesoterodine, solifenacin, 
darifenacin, propiverine, and trospium.

Phosphodiesterase type 5 inhibitors

Will be offered to men with moderate-to-severe LUTS with or without erectile dysfunction.

Currently available medications for this purpose: tadalafil

Beta-3 agonists

Will be offered to men with moderate-to-severe LUTS who mainly have bladder storage symptoms.

Currently available medications: Mirabegron 



Medical Treatment of Benign Prostatic Hyperplasia- BPH

α1-blocker + a 5α-reductase inhibitor 

May be offered to men with moderate-to-severe LUTS and a prostate volume > 40 mL.

α1-blocker+muscarinic receptor antagonist

May be offered to men with moderate-to-severe LUTS if relief of storage symptoms has been insufficient with monotherapy with either drug.

Desmopressin

We may offer desmopressin to men men < 65 years who have nocturia due to nocturnal polyuria.

We may offer low dose desmopressin to men men > 65 years who have nocturia due to nocturnal polyuria.

Patients should avoid drinking fluids at least one hour before and eight hours after dosing. 

Patient needs to be screened for hyponatremia at baseline, day three and day seven, one month after initiating therapy and periodically during treatment. Na needs to be checked more frequently in high risk patients and in men > 65.


Indication for surgery

Lower urinary tract symptoms due to BPH refractory to other therapies.

Refractory urinary retention secondary to BPH

Renal insufficiency secondary to BPH
 
Recurrent urinary tract infections 

Recurrent bladder stones 

Gross hematuria due to BPH

Surgical treatment options for BPH

Open, laparoscopic or robotic assisted prostatectomy 

For patients with prostate size > 80 mL.

TURP

Monopolar or bipolar- for patients with prostate size of 30-80 mL.

TUIP

For patients with prostate size <30 mL

TUVP- Transurethral Vaporization of the Prostate

Bipolar- for patients with prostate size of 30-80 mL.

PVP- Photoselective Vaporization of the Prostate - Green light laser

120W or 180W platforms- for patients with prostate size of 30-80 mL.

PUL- Prostatic Urethral Lift

For patients with prostate size <80 mL and no obstructive middle lobe.

TUMT- Transurethral Microwave Therapy 

For patients with prostate size <80 mL and no obstructive middle lobe.

Water Vapor Thermal Therapy

For patients with prostate size <80 mL

Laser Enucleation

Holmium laser or  thulium laser- size-independent options. 

Aquablation

For patients with prostate size of 30-80 mL.