Benign Prostatic Hyperplasia

• The patient is below 50 years of age.
• DRE is suspicious (nodules or induration)
• Plasma PSA is above 10 µg/l, in patients below 65 years of age the threshold value varies depending on the age group. Check the reference values used by the laboratory you use. Determination of free PSA is recommended if total PSA is in the range 2.5-10 µg/l.
• Interpretation of PSA value:
  • Reference values of total PSA concentration in men of different ages Prostate Cancer
  • PSA concentration, proportion of free PSA and the probability of prostate cancer Prostate Cancer
  • Digital rectal examination before determination of plasma PSA concentration does not influence the result.
  • See also the article PSA test in prostate cancer screening Psa Test in Prostate Cancer Screening.
• Rapidly developing symptoms
• Haematuria (cystoscopy)
• Patients with diabetes who may have neuropathy
• History of pelvic surgery or irradiation
• Neurological disease or injury affecting the function of the urinary bladder
• Necessary medication affecting the function of the urinary bladder
• Lower abdominal pain as the main symptom
• Discrepancy between symptoms and findings
• The investigations performed by the urologist include
  • always
    • urine flow measurement http://www.dynamed.com/condition/benign-prostatic-hyperplasia-bph#NONINVASIVE_URODYNAMIC_TESTING
    • transrectal ultrasonography http://www.dynamed.com/condition/benign-prostatic-hyperplasia-bph#PROSTATE_ULTRASOUND,
  • and if necessary also
    • cystometry and pressure-flow examination (recommended before deciding on surgery if the peak flow is >10 ml/s http://www.dynamed.com/condition/benign-prostatic-hyperplasia-bph#PRESSURE_FLOW_STUDIES__PFS_ and also when there is a discrepancy between symptoms and findings or the patient has earlier undergone surgery of the lower urinary tract)
    • urethrocystography
    • ultrasonography of the urinary tract http://www.dynamed.com/condition/benign-prostatic-hyperplasia-bph#URINARY_TRACT_IMAGING
    • prostatic biopsies
    • cystoscopy http://www.dynamed.com/condition/benign-prostatic-hyperplasia-bph#CYSTOSCOPY.

Surgical treatment is indicated in the following cases:

• Urinary retention, overflow incontinence or repeatedly more than 300 ml of residual urine
• Severe symptoms not relieved by drug therapy
• Severe narrowing based on measurement of flow rate
• Dilatation of the upper urinary tract
• Impairment of renal function
• Recurrent macroscopic haematuria
• Urinary tract infections
• Bladder calculi
• Severe or moderate symptoms in a patient who wants rapid and effective relief or if satisfactory results have not been obtained with other treatments.

Follow-up

• As the symptoms of BPH vary greatly and the course of the disease in an individual cannot be fully predicted, follow-up http://www.dynamed.com/condition/benign-prostatic-hyperplasia-bph#WATCHFUL_WAITING is a suitable approach in patients with mild symptoms. Also in moderate symptoms, follow-up can be the initial approach if the symptoms do not essentially affect the quality of life and complications have not developed.
• Follow-up includes explaining to the patient the nature of the disease and carrying out basic investigations annually or when symptoms change. Opportunistic follow-up during other encounters in primary care is one follow-up method.

Drug treatment Naftopidil for the Treatment of Lower Urinary Tract Symptoms Compatible with Benign Prostatic Hyperplasia

• Although the effectiveness of drug treatment is not as good as that of surgery it is often sufficient for reducing or alleviating the symptoms.
• When deciding on the treatment, the overall economic implications should also be considered, i.e. to determine when would invasive therapy, which usually gives complete cure, cost less and be more convenient for the patient than drug therapy continuing for years.
• Patients on drug treatment should be followed up regularly at 6-12-month intervals to detect complications resulting from urethral obstruction.
• The size of the prostate and total plasma PSA guide the selection of therapy: if the prostate is not markedly enlarged on palpation or in ultrasonography (< 30 ml) and PSA is < 1.5 µg/l the first choice is an alpha₁-blocker http://www.dynamed.com/management/medical-therapies-for-benign-prostatic-hyperplasia-bph-17#ROLE_OF_ALPHA_BLOCKERS,tamsulosin or alfuzosin. If the prostate is markedly enlarged or PSA is > 1.5 µg/l either 5-alpha-reductase inhibitor http://www.dynamed.com/management/medical-therapies-for-benign-prostatic-hyperplasia-bph-17#ARI_ROLE_AND_DOSING (finasteride, dutasteride)5-Alpha-Reductase Inhibitors (5ARI) for Benign Prostatic Hyperplasia or an alpha₁-blocker can be used.
• A combination of 5-alpha-reductase inhibitor and alpha₁-blocker http://www.dynamed.com/management/medical-therapies-for-benign-prostatic-hyperplasia-bph-17#COMBINATION_OF_ALPHA_BLOCKERS_AND_5_ARI alleviates symptoms more effectively than either drug alone Combination of Doxazosin and Finasteride Compared with Either Drug Alone or Placebo for Benign Prostatic Hyperplasia.

Alpha-blockers Terazosin for Benign Prostatic Hyperplasia

• TamsulosinTamsulosin for Benign Prostatic Hyperplasia, alfuzosin
• Alpha₁-blockersalleviate symptoms, increase peak urinary flow and reduce the volume of residual urine.
• The effect of alpha₁-blockers is seen rapidly and continues for several years. The drugs can also be used periodically when symptoms become worse.
• The patients should be followed up initially at 1-3-month intervals.
• Possible side effects include dizziness, postural hypotension, and missing of ejaculation, which is more rare with alfuzosin than with tamsulosin.

5-alpha-reductase inhibitors (5ARI)

• The dose of finasteride is 5 mg once daily and that of dutasteride is 0.5 mg once daily.
• The drugs affect the natural course of benign prostatic hyperplasia 5-Alpha-Reductase Inhibitors (5ARI) for Benign Prostatic Hyperplasia and significantly reduce the risk of urinary retention and need for invasive treatment, and, moreover, the treatment response is long-lasting. The drugs decrease prostatic size but the prostate returns to its original size a few months after discontinuation of treatment.
• The drugs are well tolerated, and the only significant adverse effects are associated with sexual functions (reduced libido, ejaculatory and erectile dysfunction). These occur in about 5-19%.
• The effect starts slowly, sometimes as late as 6 months after the onset of treatment. If no effect is observed in 6 months, the patient's situation and indications for possible surgery should be reconsidered.
• Although treatment with 5ARIs decreases plasma PSA level by about 50% this makes follow-up no more difficult than with alpha-blockers: an increasing PSA concentration is an indication for further urological investigations.

Phosphodiesterase-5 inhibitors

• Particularly the long-acting tadalafil http://www.dynamed.com/management/medical-therapies-for-benign-prostatic-hyperplasia-bph-17#GUID-559451E9-0C50-4922-AC72-AFB3A7819DF7 at a dose of 5 mg daily has been shown to alleviate symptoms associated with urination significantly better than placebo. The more short-acting sildenafil and vardenafil can also be used.
• These drugs are particularly suitable for patients with mild to moderate urination symptoms and concomitant need of treatment for erectile dysfunction.

Plant extracts (phytotherapy) Pygeum Africanum for Benign Prostatic Hyperplasia, Serenoa Repens for Benign Prostatic Hyperplasia, Phytotherapy for Benign Prostatic Hyperplasia

• Plant extracts are prepared from e.g. pumpkin seeds and berries of American saw palmetto (Serenoa repens).
• Their efficacy has not been verified in randomized controlled trials.