APPROACH TO BENIGN PROSTATIC HYPERPLASIA (BPH)

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Benign prostatic hyperplasia (BPH) is a histologic diagnosis characterized by the proliferation of glandular epithelial tissue, smooth muscle, and connective tissue within the prostatic transition zone. 

 

The average prostate is approximately 20 cc between the ages of 21 and 30. BPH can begin to develop in the early 40s in some men and is found in 50% of men ages 51 to 60. The prevalence of BPH increases steadily with age, reaching 60% at age 60 and 80% at age 80.

 

An enlarged prostate gland can result in lower urinary tract symptoms, either by directly obstructing the bladder outlet as enlargement changes the shape of the gland, or by increasing smooth muscle tone and resistance to flow within the enlarged gland.

 

Most men will develop benign prostatic hyperplasia (BPH), which can be associated with lower urinary tract symptoms (LUTS). The common clinical manifestations of LUTS/BPH include storage symptoms (increased daytime frequency, nocturia, urgency, and urinary incontinence) and voiding symptoms (slow urinary stream, splitting or spraying of the urinary stream, intermittent urinary stream, hesitancy, straining to void). 

 

Here’s the American Urological Association Guideline Recommendation for the Management of LUTS Attributed to BPH: 

 

In evaluating patients presenting with bothersome LUTS possibly attributed to BPH, clinicians should obtain a medical history, conduct a physical examination, utilize the International Prostate Symptom Score (IPSS), and perform a urinalysis. 

 

International Prostate Symptom Score (IPSS). The American Urological Association recommended using the IPSS to help establish a diagnosis and to monitor the efficacy of interventions. This is a validated 8-point questionnaire that numerically characterizes patient symptoms. Three questions pertain to storage symptoms (frequency, nocturia, urgency), and four pertain to voiding (feelings of incomplete emptying, weak stream, intermittency, straining). The final question assesses the self-reported impact of symptoms on patient quality of life. The IPSS is not a reliable diagnostic tool; instead, it is best used to measure LUTS after establishing a diagnosis. 

 

Patients should be evaluated by their providers 4-12 weeks after initiating treatment (provided adverse events do not require earlier consultation) to assess their response to therapy. Re-evaluation should include the IPSS. 

 

The primary goal of treating BPH is to improve quality of life (by minimizing bothersome symptoms of LUTS) and prevent complications of acute urinary retention.

 

For patients with IPSS scores 0-7, we recommend conservative management. This might include fluid restriction, avoiding fluids before bed, daytime leg elevation and use of compression stockings, adjustment of diuretics' timing to avoid overnight diuresis, minimization of bladder irritants, and discontinuation of medications that might worsen symptoms.

 

Medical therapy and procedural treatments may be considered for patients with moderate to severe baseline lower urinary tract symptoms or those unresponsive to conservative management.

 

Clinicians should discuss pharmacologic treatment in patients with moderate to severe symptoms (AUA/IPSS ≥8) or symptoms that significantly impact quality of life and in patients at risk for urinary retention.

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Alpha-blockers

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Blocking α-adrenergic receptors relaxes smooth muscles in the prostate and bladder neck, reducing dynamic obstruction and improving urinary flow.

 

There are five main alpha-blocker medications. The second-generation drugs include terazosin and doxazosin, while the third-generation drugs are tamsulosin, alfuzosin, and silodosin. Third-generation drugs are generally well tolerated, with tamsulosin specifically associated with fewer side effects.

 

Given the similar efficacy of different alpha-blockers, switching medications is generally not recommended if a patient does not achieve an adequate therapeutic response with the initial drug.

 

Alpha-blockers generally take 3 to 7 days to reach their maximum effect. 

 

Because α-adrenergic receptors are found throughout our vascular and central nervous systems, α-blockers can have substantial side effects, including hypotension, fatigue, peripheral edema, retrograde ejaculation, and dizziness. 

 

Ejaculatory dysfunction results from the relaxation of the smooth muscle within the prostatic and ejaculatory ducts with the alpha blockade. Some urologists favor alfuzosin to reduce ejaculatory symptoms.