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Non-Surgical Managment

Common BPH drugs

Drug	Dosing	Uro-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%)
Mirabegron (Myrbetriq)	25-50mg daily	No	No	nasopharyngitis (3-6%), headache (2-3%), hypertension (10-12%)
Vibegron (Gemtesa)	75mg daily	No	No	nasopharyngitis (3-6%), headache (2-3%)

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-Agonists

• Mechanism: stimulates bladder relaxation
• Dosing: mirabegron 25-50mg daily, vibegron 75mg daily
• Effects: reduces storage symptoms, increases PVR by average 30mL

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

1. RALP may have increased risk for incontinence due to bladder neck reconstruction
2. RALP age cutoff 70 (with exceptions), whereas RASP has no age cutoffs
3. RASP + XRT may be better option for continence and prostate cancer than RALP
4. MRI prostate, PSA, and biopsy will not change need for RASP (or other outlet procedure)
5. Can perform biopsy at time of RASP
6. Can consider XRT or other adjuvant therapies based on post-RASP PSA
7. 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)