Benign Prostatic Hyperplasia (BPH)

Background

• BPH is a histologic condition of proliferation of smooth muscle and epithelial cells in prostatic transition zone.
• Bothersome lower urinary tract symptoms (LUTS) associated with BPH may include voiding symptoms (weak or intermittent urinary stream, straining, and hesitancy), storage symptoms (urgency, frequency, nocturia, urgency incontinence, and urinary retention), and postmicturition dribbling.
• BPH most commonly affects older adults ≥ 40 years old.
• Complications of BPH are infrequent, but can include acute urinary retention, urinary tract infection, renal insufficiency, and bladder stones.

Evaluation

• Following is an excerpt. See Diagnostic Approach in Lower Urinary Tract Symptoms in Male Adults for details.
• Perform complete history and physical (Strong recommendation), including
  • evaluation of symptom severity and impact on quality of life with validated symptom scores (Strong recommendation)
  • digital rectal exam (Strong recommendation)
  • bladder diary for ≥ 3 days if prominent storage symptoms, overactive bladder symptoms, or nocturia are present (Strong recommendation)
  • assessment of neurologic function
• Initial testing includes urinalysis (Strong recommendation), serum prostate-specific antigen (PSA) (if it will impact management decision-making for prostate cancer) (Strong recommendation), postvoid residual (PVR) (Weak recommendation), and uroflowmetry (Weak recommendation).
• Consider additional evaluations as necessary if etiologies other than BPH are suspected based on initial evaluations.
• If medical or invasive management (such as surgical management) is necessary, additional evaluations may be necessary.

Management

• Offer lifestyle advice and self-care information before or in addition to medical and/or surgical management (Strong recommendation), which may include behavioral modifications and dietary modifications.
• For patients who are not bothered by mild-to-moderate LUTS, offer watchful waiting (Strong recommendation).
• Consider referral to urologist if patients who have LUTS that are not relieved by behavioral and/or medical management, who present with severe symptoms, or if etiologies other than BPH are suspected (Weak recommendation).
• Medical management:
  • For patients with moderate-to-severe bothersome LUTS from BPH or for those patients interested in pharmacologic management, offer an alpha blocker (Strong recommendation).
  • Exercise caution when offering alpha blockers if the patient is undergoing cataract surgery (due to risk of intraoperative floppy iris syndrome), at risk for orthostatic hypotension, or taking a phosphodiesterase-5 inhibitor (PDE5I). However, combination of alpha blockers with PDE5Is is generally not suggested due to no symptomatic improvement over monotherapy (Weak recommendation).
  • Alternatives to alpha blockers:
    • Offer PDE5I regardless if patients have erectile dysfunction (Strong recommendation).
    • For patients with LUTS secondary to BPH who have prostate enlargement, offer 5-alpha reductase inhibitors (5-ARIs) as monotherapy or combination therapy with alpha blockers (Strong recommendation).
      • 5-ARIs can have a slow onset of action.
      • 5-ARIs carry a warning about being associated with a small increased risk of high-grade prostate cancer.
    • For patients with predominantly bladder storage LUTS secondary to BPH:
      • Consider anticholinergics (muscarinic receptor antagonists) (Weak recommendation).
        • For patients with storage symptoms not alleviated by monotherapy of either alpha blockers or anticholinergics, offer a combination of both (Strong recommendation).
        • Consider not offering alpha blockers plus anticholinergics if postvoid residual is > 150 mL (Weak recommendation).
      • Consider beta-3 agonists (Weak recommendation). If patients have persistent storage symptoms after alpha blocker monotherapy, consider combination therapy with alpha blocker plus mirabegron (Weak recommendation).
• Procedural management:
  • Procedural interventions are indicated when conservative or medical managements do not adequately relieve symptoms or when complications of BPH arise.
  • Management of patients who can tolerate anesthesia and suspension of anticoagulation or antiplatelet therapy:
    • For patients with prostate size < 30 mL and absence of middle lobe, perform transurethral incision of prostate (TUIP) as the preferred management option ( Strong recommendation).
    • For patients with prostate size 30-80 mL, perform monopolar or bipolar transurethral resection of prostate (TURP) as the preferred management option ( Strong recommendation).
    • For patients with prostate size > 80 mL, the preferred management options include holmium laser enucleation of prostate (Ho:LEP) ( Strong recommendation), or bipolar transurethral enucleation of prostate (B-TUEP) ( Weak recommendation), or open prostatectomy if Ho:LEP or B-TUEP is not available ( Strong recommendation).
  • For management of high-risk patients who can tolerate anesthesia, but cannot suspend anticoagulation or antiplatelet therapy, perform green light laser photoselective vaporization of prostate (PVP) as the preferred management option (Strong recommendation).
  • For management of high-risk patients with prostate size < 70 mL and absence of middle lobe who cannot tolerate anesthesia, consider prostatic urethral lift (PUL) if patients prefer to preserve ejaculatory function (Weak recommendation).
• For management of urinary incontinence, see Urinary Incontinence in Men for details.