Benign prostatic hyperplasia (BPH) is a common condition in aging men, and a range of effective medical and interventional treatments are available to manage its bothersome urinary symptoms and prevent complications.

Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland, a common condition affecting a significant proportion of aging men [1, 6]. As men age, the cells within the prostate's transition zone can proliferate, leading to an increase in prostate size [4, 5]. This enlargement can cause the prostate to press on the urethra, the tube that carries urine out of the body, resulting in bothersome lower urinary tract symptoms (LUTS) [2, 3, 4, 5, 6].

These symptoms often include a weak urine stream, difficulty starting urination, frequent urination, urgency, and a feeling of incomplete bladder emptying [6]. If left unmanaged, BPH can progress, potentially leading to more serious complications such as acute urinary retention (the sudden inability to urinate) or the need for surgical intervention [2, 7]. Emerging evidence also suggests that chronic inflammation within the prostate may contribute to the development and progression of BPH [4].

Initial Steps and Medical Management

The primary care physician plays a crucial role in the early identification and initial treatment of BPH-related urinary symptoms [1]. This typically involves a detailed medical history and a physical examination to assess the condition [1, 5]. The initial goals of BPH therapy are not only to alleviate bothersome LUTS and improve urinary flow but also to identify patients at risk of disease progression and optimize their management [7].

While primary care providers can initiate various medical treatments, it is also very important for them to determine when further evaluation and referral to a urologist are necessary, especially if surgical intervention might be considered [1]. There is a growing trend for BPH to be managed increasingly in primary care settings, which emphasizes the need for collaborative care between primary and specialty care to ensure optimal use of resources and expertise [2].

Medications for BPH

For many men with BPH, medication is the first line of treatment to manage symptoms. Several classes of drugs are commonly used:

Alpha-blockers: These medications work by relaxing the muscles in the prostate and bladder neck, which can improve urine flow and reduce symptoms [1, 2].
5-alpha reductase inhibitors (5ARIs): Medications like finasteride and dutasteride belong to this class [1, 2, 6, 7]. They work by blocking the conversion of testosterone to dihydrotestosterone, a hormone that contributes to prostate growth, thereby reducing prostate size [6]. 5ARIs can significantly reduce the risk of disease progression and help avoid long-term complications such as acute urinary retention and the need for surgery [2, 7].
Phosphodiesterase-5 inhibitors (PDE5i): These medications are also used in the management of BPH symptoms [1].

For some patients, particularly those at higher risk of disease progression, a combination of an alpha-blocker and a 5ARI has shown strong evidence in large randomized trials to significantly reduce the risk of disease progression and prevent complications [2, 7].

Minimally Invasive Office Procedures

When medications are not sufficient or well-tolerated, or for patients seeking alternatives, several minimally invasive procedures can be performed in an outpatient setting, often under local anesthesia [3]. These procedures offer benefits such as decreased hospitalization, shorter operative times, and reduced catheterization periods, potentially leading to cost savings [3].

Two popular office-based options include:

Prostatic Urethral Lift (UroLift): This procedure involves placing small implants to hold open the enlarged prostate tissue, thereby relieving obstruction of the urethra. UroLift has demonstrated excellent efficacy and durability in relieving LUTS in BPH patients [3].
Convective Water Vapor Ablation (Rezum): This therapy uses targeted bursts of steam to shrink the excess prostate tissue. Rezum has also shown excellent efficacy and durability in improving LUTS for BPH patients [3].

These novel therapies provide effective alternatives to more invasive surgical options, often with a favorable safety profile [3].

Advanced Surgical Options

For men with more severe symptoms, larger prostates, or those who have not responded to other treatments, more advanced surgical interventions may be recommended. For many years, Transurethral Resection of the Prostate (TURP) has been considered the gold standard surgical therapy for LUTS secondary to BPH [3, 8].

More recently, newer treatment modalities have emerged, offering similar efficacy with potentially improved adverse event profiles:

Aquablation: This is a modern technology that uses a robotically controlled, high-velocity water jet to precisely remove prostate tissue that is obstructing the urethra [8]. Aquablation has been shown to be rapidly effective in treating LUTS due to BPH. Critically, in comparisons with TURP, Aquablation has demonstrated equivalent objective results with much shorter resection times and significantly improved postoperative sexual function [8].

When to See a Urologist

While primary care physicians are instrumental in the initial diagnosis and management of BPH, knowing when to consult a urologist is key for optimal care [1]. A referral to a urologist is generally recommended if your symptoms are bothersome and significantly impacting your quality of life, if initial medical treatments are not providing adequate relief, or if there are concerns about potential complications [1]. A urologist can provide a more specialized evaluation, discuss a broader range of treatment options including advanced medical therapies, minimally invasive procedures, and surgical interventions, and help tailor a management plan based on individual risk factors and preferences [1, 2].

Sources

This article summarises published research for a general audience. It is not medical advice — talk to a qualified clinician about your own situation. Need help finding one? Browse doctors.