Fast Five Quiz: Benign Prostatic Hyperplasia Key Aspects

Bradley Schwartz, DO


January 12, 2021

Watchful waiting is the recommended strategy for patients with BPH who have mild symptoms (International Prostate Symptom Score/AUA Symptom Index [IPSS/AUA-SI] score ≤ 7) and for those with moderate to severe symptoms (IPSS/AUA-SI score ≥ 8) who are not bothered by their symptoms and are not experiencing complications of BPH. In those patients, medical therapy is not likely to improve symptoms and/or quality of life. In addition, the risks of treatment may outweigh any benefits in such cases. Patients managed expectantly with watchful waiting are usually re-examined annually.

According to AUA guidelines, if drug therapy is considered in patients who predominantly have symptoms of bladder outlet obstruction, alpha-adrenergic blocking agents are the first treatment of choice for LUTS due to BPH. However, alpha-blockers alone, 5-alpha-reductase inhibitors alone, and/or combination alpha-blocker and 5-alpha-reductase inhibitor therapy have shown the most efficacy when the prostate is enlarged as assessed by PSA levels, transrectal ultrasound, or on digital rectal examination. Obstruction from BPH can also manifest as urinary urgency. Thus, reducing the obstruction may ease the irritative symptoms of BPH.

AUA guidelines also advise that combination therapy with an alpha-blocker and a 5-alpha-reductase inhibitor can be appropriate and effective for patients with LUTS who have enlarged prostates. The alpha-1-receptor blocker provides rapid relief, while the 5-alpha-reductase inhibitor targets the underlying disease process.

AUA guidelines recommend anticholinergic agents for management of LUTS in patients who do not have an elevated postvoid residual urine volume (PVR) and whose LUTS are primarily irritative. Baseline PVR should be measured prior to initiation of anticholinergic therapy to assess for urinary retention. Caution with anticholinergics is recommended with patients whose PVR is > 250-300 mL.

Read more about the treatment of BPH.


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