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Evaluation/Workup

History

• Assess baseline symptoms: (voiding + storage), use AUASS
• Common conditions causing LUTS: DM, neurologic, CKD/CHF, OSA, cancer
• Fluid intake: assess amount and timing
• Bladder irritants: caffeine, alcohol, spicy food, acidic food
• Medications: a-agonists, anticholinergics

Clinic tests

• DRE: prostate cancer PPV 6-33%, poor estimate of prostate size
• PVR: no standardized definition or unified cutoff, questionable association with developing acute retention
• Uroflow: inaccurate if < 125-150mL, cannot distinguish BOO from DUA, consider 15mL/s a reasonable cutoff
• Cystoscopy: consider for gross hematuria, history bladder cancer, history recurrent UTIs or urethral injury, history prior urethral surgery, and prior to surgical planning, cannot accurately predict prostate size
• UDS: recommended if prior surgical therapy, unable to void > 150mL, PVR > 300mL, concern for neurologic disease, prior pelvic surgery, age > 80 or < 50 and predominantly voiding symptoms

BPH Labs

• UA: may be helpful for identifying UTI or hematuria
• Cytology: consider if severe storage symtpoms, dysuria, and smoking history
• PSA: consider checking after discussing risks/benefits and need for further workup, only check if cancer diagnosis will change BPH management (life expectancy > 10yrs)
• Renal fxn: check if considering surgical management (increased postop risks)

Non-Surgical Managment

Common BPH drugs

Drug	Dosing	Selective?	Titration?	Side effects
Terazosin (Hytrin)	2-5mg QHS	No	Yes	dizziness (14-17%), asthenia (5-13%) headache (5-13%), hypotension (2%)
Doxazosin (Cardura)	2-8mg QHS			dizziness (5%), headache (5%)
Alfuzosin (Uroxatral)	10mg QHS		No	dizziness (12%), asthenia (5%), hypotension (3%), CV effects (10%)
Tamsulosin (Flomax)	0.4-0.8mg QHS	Yes (a1A)		dizziness (3-15%), asthenia (24%), headache (5-16%), retrograde ejaculation (1-18%), CV effects (9%)
Silodosin (Rapaflo)	8mg QHS			retrograde ejaculation (10-14%), dizziness (8%), headache (3%)
Finasteride (Proscar)	5mg daily	Type 2		decreased libido (4-5%), ejaculatory dysfunction (4%), erectile dysfunction (6%), gynecomastia/breast tenderness (0.5-1%), cardiac failure (1%)
Dutasteride (Avodart)	0.5mg daily	No (Type 1 + 2)
Tadalafil (Cialis)	5mg daily	Yes	No	headache (13%), dyspepsia (7%), flushing (7%)

Conservative Management

• Watchful waiting: reasonable for mild symptoms, check symptoms annually
• Fluids: maintain 1.5-2L intake (adjust as needed), decrease caffeine/alcohol
• Nocturia prevention: restrict fluids 2-4hrs before bed, elevate legs if edema present, avoid evening diuretics
• Behavioral: timed voiding, double voiding, "urethral milking" (for postvoid dribbling)
• Constipation: avoid

Alpha-blockers

• Mechanism: a-receptor blockade leads to smooth muscle relaxation at bladder neck, prostate, and proximal urethra
• Receptor subtypes: a1A found in prostate/bladder neck smooth muscle, a1B found in blood vessels, a1D found in nasal passages, bladder, and spinal cord
• Effects: improves symptom scores by 30-40% and uroflow parameters by 20-25%, no effect on prostate size or PSA
• CV effects: alfuzosin increases CV effects, whereas tamsulosin/silodosin do not interact with cardiac medications
• Sexual effects: no proven effect on erectile function or libido, but tamsulosin/silodosin cause retrograde ejaculation and orgasmic impairment in ~17%
• Intraoperative floppy iris syndrome (IFIS): occurs during cataract surgery after a-blocker exposure, can occur even after drug discontinuation, tamsulosin (30-88%), alfuzosin (15-70%), doxazosin (2-45%)

5a reductase inhibitors

• Mechanism: prevents conversion of T to DHT, inhibiting prostate growth
• Effects: reduces prostate volume 20-25%, improves flow rate by 10%, improves symptom scores 20-30%, decreases urinary retention risk 50%, reduces need for prostate surgery 50%, decreases PSA 50%, decreases recurrent hematuria risk, takes 6 months for full effect
• Indications: prostate > 30g and PSA > 1.5
• Prostate cancer risk: potentially increases high-risk prostate cancer, although actual effect unclear

Anticholinergics

• Mechanism: antagonism of bladder muscarinic receptors results in bladder relaxation, decreasing bladder spasms
• Effects: reduces stoarge symptoms, increases PVR by an average of 25mL, < 3% retention risk
• Indications: most beneficial in patients with high storage symptom scores, high flow rate (> 5mL/s), low PVR (< 200mL), no hx retention
• Options: darifenacin 7.5-15mg QD, fesoterodine 4-8mg QD, oxybutynin IR 2.5-5mg 3-4x daily, oxybutynin ER 5-15mg QD, solifenacin 5-10mg QD, trospium 60mg QD or 20mg BID
• Side effects: dry mouth (≥ 16%), constipation (≥ 4%), dizziness (≥ 5%), and cognitive dysfunction

B3-Agonist - Mirabegron

• Mechanism: stimulates bladder relaxation
• Dosing: 25mg QD, titrate up to 50mg
• Effects: reduces storage symptoms, increases PVR by average 30mL
• Side effects: nasopharyngitis (3-6%), headache (2-3%), hypertension (10-12%)

Phosphodiesterase Type 5 inhibitors

• Mechanism: may increase oxygenation of tissue, relax bladder neck and prostate smooth muscle, decrease stromal proliferation and inflammation
• Effects: symptom score improvement 20-30%, may also improve flow rate, usually improves within 1 week but can take up to 2mo
• Tadalafil 5mg is currently the only option recomended for LUTS

Phytotherapy

• Different extracts and preparations have widely variable amounts of "active" ingredients
• Efficacy: all evidence is based on in vitro studies, no good long-term clinical evidence exists that phytotherapy is beneficial
• Common types: saw palmeto, African plum tree, stinging nettle, pumpkin seed, African star grass, rye grass pollen

Surgical Management

Indications for Surgery

• Hematuria: finasteride has proven benefit for decreasing further episodes, confirm BPH as cause with hematuria workup, can consider BPH surgical management at time of clot evacuation
• Bladder stones: can consider medical management after removal of bladder stones
• Recurrent UTIs: may be secondary to incomplete emptying
• Urinary retention: idiopathic vs iatrogenic, up-front surgery not recommended, 60% pass first voiding trial, up to 80% have another retention episode within 6 months
• Upper tract injury: not necessary to screen prior to interventions, if secondary to BOO then place catheter and reassess, bladder wall hypertrophy may cause persistent obstruction and require stenting
• Bladder diverticulum: not a clear indication unless related UTIs or bladder decompensation
• Medication failure: surgery recommended if bothersome symptoms persist despite maximal medical therapy

Choosing the right surgery

• Prostate size: prostates > 80-150g benefit from HOLEP or simple prostatectomy
• Anticoagulation: consider PVP/KTP, HoLEP to minimize bleeding
• Ejaculatory function: urolift, Rezum, and aquablation are more likely to maintain antegrade ejaculatory function postoperatively
• Median lobe: urolift less efficacious
• Prior prostate cancer treatment: prior cryotherapy or XRT increases risk for postoperative incontinence
• Laser type: KTP absorbed by Hgb, holmium/thulium absorbed by water
• Other considerations: risks/benefits, prior surgeries, surgeon experience, patient preference
• Workup: patient should undergo cystoscopy + sizing to assess best treatment option, can consider urodynamics prior to surgery if unclear cause of symptoms
• Incidental cancer diagnosis: if PSA < 4, cancer diagnosed in 1/382 TURPs (uncommon)
• See the separate page for technique info about TURP, UroLift, PVP, and TUIP

Clinical scenario: patient with > 100g prostate, with(out) urinary retention, and no prior prostate cancer workup

• RALP may have increased risk for incontinence due to bladder neck reconstruction
• RALP age cutoff 70 (with exceptions), whereas RASP has no age cutoffs
• RASP + XRT may be better option for continence and prostate cancer than RALP
• MRI prostate, PSA, and biopsy will not change need for RASP (or other outlet procedure)
• Can perform biopsy at time of RASP
• Can consider XRT or other adjuvant therapies based on post-RASP PSA
• THEREFORE: in patient with 100+g prostate, can offer up-front RASP with truncated prostate cancer workup to avoid delaying treatment of urinary retention, but has risk of requiring XRT afterwards (difficult to perform RALP after RASP)

References

• AUA Core Curriculum
• Capogrosso, P., A. Salonia, and F. Montorsi. "Evaluation and Nonsurgical Management of Benign Prostatic Hyperplasia." Campbell-Walsh Urology 12 (2020).
• Helo, S., C. Welliver, and K. McVary. "Minimally Invasive and Endoscope Management of Benign Prostatic Hyperplasia." Campbell-Walsh Urology 12 (2020).
• Parsons, J. Kellogg, et al. "Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline amendment 2020." The Journal of urology 204.4 (2020): 799-804.
• Wieder JA: Pocket Guide to Urology. Sixth Edition. J.Wieder Medical: Oakland, CA, 2021.