Benign Prostatic

Hyperplasia
Anoop Agrawal, M.D.
Baylor College of Medicine
Med-Peds Continuity Clinic
Prevalence of BPH
AUA BPH Algorithm
 Medical History
• Seven cardinal symptoms:
• urinary frequency
• nocturia
• urgency
• hesitancy
• weak
• straining to void
• sensation of incomplete voiding
 Initial Evaluation
• History
• Digital Rectal Exam & Focused Physical
• Urinalysis
• PSA
• AUA Symptom Index Score
 BPH: Diagnosis

• Palpable prostate size does not correlate

with a diagnosis of BPH, nor with degree of
obstruction or the severity of symptoms.

• Use urinary symptom scoring scale by the

American Urological Association to aid with
diagnosis.

• consists of seven questions - each

question grades severity of each symptom
 Differential Diagnosis
• Diabetes
• UTI
• Neurogenic bladder
• Urethral strictures
• Cancer (bladder or prostate)
• Medication induced
 Laboratory Testing
• Urinalysis
• PSA
• Optional tests:
• urinary flow rate measurements
• postvoid residual urine measurements
• pressure flow studies
AUA Symptom Index
 AUA Symptom Index:
Interpretation
• Classification:
• Mild: 0-7
• Moderate: 8-19
• Severe: 20-35
• The AUA score needs to be put in the
context of whether the condition is or is not
bothersome.
 Treatment
• Studies have found that over a follow-up
period of 2.6 to 5 years, 16% men had stable
symptoms and 38% improved over time.

• Treatment choices must take into account:

• Symptom Index Score
• Effect on quality of life
 Case One
• A 62 yo man reports nocturia, frequency and
urgency. His UA is negative, PSA is normal.
His AUA Severity Index is 10. He states the
symptoms are not very bothersome. What
treatment options do you recommend?

• A. Watchful waiting
• B. alpha-1 blocker
• C. 5-alpha reductase inhibitor
• D. Surgical therapy
 Case One
• A 62 yo man reports nocturia, frequency and
urgency. His UA is negative, PSA is normal.
His AUA Severity Index is 10. He states the
symptoms are not very bothersome. What
treatment options do you recommend?

• A. Watchful waiting
• B. alpha-1 blocker
• C. 5-alpha reductase inhibitor
• D. Surgical therapy
 Treatment
• Though symptom score may be above the
Mild range (0-7), initiating medical therapy is
not warranted unless patient finds he is
bothered by the symptoms.

• May begin with behavior modifications:

• reducing fluid intake at night
• reducing consumption of mild diuretics
(caffeine and alcohol)
 Treatment
• Alpha-1 Blockers - common first line agent
• Rapid onset, reduction in symptom score
by 30-40%

• Nonselective Alpha-1 Blockers

• SE: dizziness, orthostatic
hypotension, fatigue, asthenia;
occurs in 7-9%

• Selective Alpha Blocker (tamsulosin,

alfuzosin) - less anti-hypertensive effect
 Case Two
• A 59 yo male presents with symptoms of BPH.
His rectal exam reveals a enlarged prostate.
You estimate at least 40 grams in size. His
AUA score is 16. He reports the symptoms
are very bothersome. What treatment options
do you recommend?

• A. Watchful waiting
• B. alpha-1 blocker
• C. 5-alpha reductase inhibitor
• D. Surgical therapy
 Case Two
• A 59 yo male presents with symptoms of BPH.
His rectal exam reveals a enlarged prostate.
You estimate at least 40 grams in size. His
AUA score is 18. He reports the symptoms
are very bothersome. What treatment options
do you recommend?

• A. Watchful waiting
• B. alpha-1 blocker
• C. 5-alpha reductase inhibitor
• D. Surgical therapy
 Treatment: Case Two
• 5-alpha reductase inhibitors (finasteride,
dutasteride) these require long-term treatment (6-12
months) before symptom improvement is seen

• more effective in men with large prostate

• Combination therapy with alpha-1 blocker and 5-
alpha reductase inhibitors

• found to be effective in men with severe

symptoms or men with moderate symptoms and
large prostate

• Downside is that long-term safety of finasteride is

unknown
 Combination Therapy in
BPH

McConnell, JD, Roehrborn, CG, Bautista, OM, et al. The long-term effect of doxazosin, finasteride, and
combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med 2003; 349:2387
 Case Three

• A 65 yo man with moderate symptoms of

BPH is worried about side effects from
alpha-1 blockers and wants to know if any
herbal remedies are recommended. What
do you advise?
 Case Three
• Complementary Medicine options
• Genistein - an isoflavone found in tofu/soy
products, found to decrease growth of
hyperplastic prostate tissue in histoculture,
marketed as Trinovin, dose 40 to 80mg qd.

• Saw palmetto - few side effects, safe, dosage

is 160mg bid

• A 2006 prospective trial found no improvement

in symptoms. Current recommendation is to
avoid.
 Case Four
• A 55 yo man has been experiencing chronic
intermittent hematuria for past several
months. Urology performed a flexible
cystoscopy revealing no evidence of
malignancy or atypia. PSA is normal. What
treatment option is available to suppress
gross hematuria?

• Finasteride - randomized trial of 57 men had

lower rate of recurrent hematuria (14 vs
63%)
 Surgical Treatments
• Open prostatectomy
• Transurethral Resection of the Prostate (TURP)
• Transurethral Incision of the Prostate (TUIP)
• Transurethral Microwave Thermotherapy
(TUMT)

• Transurethral vaporization of the prostate

(TUVP)

• Transurethral needle ablation of the prostate

(TUNA)
AUA BPH Algorithm
 Conclusion

• Diagnosis based upon patient’s symptom

index and affect on quality of life

• Wide range of treatment options - discuss

with patient benefits and risks.

• Surgical therapy tends to be more effictive,

but results in more residual side effects.
 References
• Bent S, et al. Saw Palmetto for Benign
Prostatic Hyperplasia. NEJM 2006;
354:557-566.

• Dull P, et al. Managing Benign Prostatic

Hyperplasia. Am Fam Physician
2002;66:77-84.

• UpToDate 2009: Medical Treatment of

benign prostatic hyperplasia. (Accessed
February 21 & 22, 2009).