Medical management of benign prostatic hypertrophy

Aim: relieve bothersome symptoms, prevent progression (acute retention, need for surgery) and preserve bladder and renal function — treatment is guided by symptom severity, degree of bother, risk of progression and patient preference.

Who to treat medically: men with moderate to severe symptoms (IPSS ≥8) who are bothered. IPSS <7 with little bother → watchful waiting plus lifestyle measures (evening fluid restriction, avoid caffeine, review diuretics, timed voiding, pelvic floor exercises, treat constipation).

α-adrenergic blockers — first-line. The bladder neck and prostatic urethra are rich in α₁-receptors; blockade relaxes smooth muscle and lowers prostatic urethral pressure. Alfuzosin 10 mg, tamsulosin 0.4 mg, silodosin 4 mg, terazosin, doxazosin. Onset within days to weeks; they do not alter the natural history. Adverse effects in 5–9%: dizziness, headache, asthenia, postural hypotension and falls, rhinitis, retrograde ejaculation. Uroselective agents (tamsulosin, silodosin, alfuzosin) are preferred in the elderly and in those on antihypertensives; warn the ophthalmologist about intraoperative floppy iris syndrome before cataract surgery.

5-α-reductase inhibitors — for the enlarged gland. Finasteride 5 mg, dutasteride 0.5 mg block conversion of testosterone to dihydrotestosterone, reducing prostate volume by up to 30%. Best in glands >30–40 mL or PSA-defined enlargement. Full effect takes 3– 6 months. They reduce acute urinary retention and the need for surgery. Side effects are mainly sexual — reduced libido, erectile and ejaculatory dysfunction, gynaecomastia. They halve serum PSA — double the measured value when interpreting it.

Combination therapy (α-blocker + 5-ARI) is appropriate when the prostate exceeds 40 mL. MTOPS: 66% reduction in acute retention with combination versus 39% (α-blocker) and 34% (5-ARI) alone; CombAT confirmed superiority of dutasteride + tamsulosin for symptom and progression outcomes. The α-blocker may be withdrawn after 6–9 months and restarted if symptoms recur.

Anticholinergics / β3-agonists may be added for persistent storage symptoms (urgency, frequency, nocturia) in men without an elevated post-void residual. Avoid in men with prior retention or cognitive impairment — anticholinergics increase delirium risk and can precipitate retention.

PDE-5 inhibitor (tadalafil 5 mg daily) improves LUTS and is particularly useful when erectile dysfunction coexists; do not combine with nitrates, and use α-blockers cautiously alongside because of additive hypotension.

Desmopressin may be considered for troublesome nocturnal polyuria in carefully selected men, with close monitoring of serum sodium (mEq/L) — hyponatraemia is common in older adults.

Phytotherapy (saw palmetto, Pygeum, beta-sitosterol) is popular and generally well tolerated, but AUA guidance does not recommend dietary supplements or combination phytotherapeutic agents for LUTS/BPH.

Failure of medical therapy, or complicated BPH (renal insufficiency, recurrent UTI, bladder stones, gross haematuria, refractory retention) is an indication for minimally invasive therapy or surgery.

Vibegron (β3-agonist) FDA-approved December 2024 for men with OAB symptoms already on pharmacological BPH therapy (COURAGE/URO-901-3005 trial) — the safest current way to add storage-symptom control to an α-blocker in an older man.

AUA LUTS/BPH Guideline 2023 amendment and 2026 update shift from a fixed ladder to shared decision-making with bladder-function preservation, revise combination-therapy statements, and reaffirm that phytotherapy is not recommended.

5-ARI safety signal: large observational data show an increased risk of depression (though not of suicide) in men on 5-α-reductase inhibitors — counsel and monitor, particularly in older men with prior mood disorder.

Mnemonic — "A-5-C-A-P": Alpha-blocker · 5-ARI · Combination · Anticholinergic/β3 · PDE-5 inhibitor.

Numerical anchors: IPSS ≥8 to treat · gland >30–40 mL for 5-ARI · 30% volume reduction · 3–6 months to act · PSA halved (double it) · MTOPS 66/39/34% · α-blocker withdrawal after 6–9 months · adverse effects in 5–9%.

The single commonest exam slip: forgetting that 5-ARIs halve PSA. State it explicitly. Examiner traps — (1) α-blockers relieve symptoms but do not prevent progression; only 5-ARIs do. (2) Do not add an anticholinergic without checking PVR. (3) Do not recommend phytotherapy as guideline-supported. (4) Remember floppy iris syndrome before cataract surgery. (5) Watch postural hypotension and falls when starting an α-blocker in a frail elder.

α-blocker = fast symptom relief; 5-ARI = shrinks gland and prevents progression.

5-ARI needs a gland >30–40 mL, takes 3–6 months and halves PSA.

MTOPS: combination cut acute retention by 66%.

Add antimuscarinic or β3-agonist for storage symptoms only if PVR is normal.

Tadalafil 5 mg daily helps LUTS plus erectile dysfunction.

Phytotherapy is not recommended by AUA guidance.