BPH — Non-Neurogenic Male LUTS

LUTS — Classification

• Storage (irritative)
• Voiding (obstructive)
• Post-micturition

Differential — LUTS is a symptom complex, not a diagnosis

Category	Causes
Prostatic	BPH
Bladder	OAB, nocturia, bladder tumor, neurogenic bladder
Outlet / urethra	Urethral stricture, foreign body
Upper tract	Distal ureteric stone
Inflammatory	UTI, CPPS

Evaluation

• Medical history & physical exam — including DRE
• Symptom score — IPSS
• Voiding diary — frequency / volume
• Urinalysis
• PVR — if high → assess upper tract
• PSA

PVR and PSA are optional in some guidelines.

AUA 2021 splits this explicitly

Recommended (3)	Optional (3)
History & physical exam	Post-void residual (PVR)
Urinalysis	Uroflowmetry
IPSS	Urodynamics

• Urinalysis → focus on glucosuria, proteinuria, hematuria, infection
• Uroflowmetry → minimum interpretable voided volume 150 cc; don't Valsalva void
  • Qmax < 10 mL/s for BOO → specificity 70%, PPV 70%, sensitivity 47%
• PVR → no accepted "significant" threshold — follow the trend; > 300 mL is worth monitoring
  • Correlation with degree of obstruction is weak; not a strong predictor of AUR
  • Elevated PVR alone is NOT an indication for surgery
• DRE is unreliable for prostate size and cannot assess a middle lobe — image if size will drive the decision
• Prostate specific gravity 1.05 → g = mL = cc interchangeably; growth ~1.6%/yr — imaging within 12 months preferred

IPSS — Scoring

Score	Severity
0–7	Mild
8–19	Moderate
20–35	Severe

The 7 domains

• Frequency
• Urgency
• Nocturia
• Weak stream
• Intermittency
• Straining
• Incomplete emptying

Cystoscopy — Indications

• Suspicious CIS
• Hematuria
• Query or history of stricture
• History of TURP
• Prior to surgical intervention

Urodynamics — Indications & Formulae

• If no clear suggestion of obstruction (Qmax > 10)

BOOI — Bladder Outlet Obstruction Index

BOOI = Pdet@Qmax − 2(Qmax)

BOOI	Interpretation
> 40	Obstructed
20–40	Equivocal
< 20	Unobstructed

BCI — Bladder Contractility Index

BCI = Pdet@Qmax + 5(Qmax)

BCI	Interpretation
> 150	Strong
100–150	Normal
< 100	Weak / acontractile

• Detrusor underactivity alone (BCI < 100) with BOOI < 40 → significantly worse 12-month Qmax after surgery — counsel carefully before TURP

Management Algorithm

Click the algorithm to open it full size.

Step	Question / Action	If YES	If NO
1	Absolute indication? — recurrent retention/UTI/hematuria · large bladder stones · hydronephrosis or renal insufficiency	Prostate US → SURGICAL TREATMENT	→ Step 2
2	LUTS bothersome by symptom score? (IPSS)	→ Step 3	Surveillance
3	Voiding diary → polyuria? — polyuria 3 L/24 h; nocturnal polyuria 33% of 24 h output at night	Fluid restriction	→ Step 4
4	Uroflow + PVR + prostate US → LUTS compatible with BPH?	Alter non-BPH factors → discuss surgical vs medical → start medical therapy (see Medical Therapy)	Evaluate & treat non-BPH

• Note the loop: the absolute indications at step 1 are the same list as the surgical indications (see Surgical Management — Indications) — minus therapy failure, which can only appear later. The algorithm asks the surgical question at the top, and again at the end of medical therapy once medical therapy fails.

Medical Therapy — Choice by Predominant Symptom

Click the algorithm to open it full size.

Predominant symptom	First line	If it crosses over
Obstructive, PV > 40	α-blocker + 5-ARI ± tadalafil	If LUTS become irritative after therapy → add OAB medication
Obstructive, PV < 40	α-blocker &/or tadalafil	(as above)
Irritative	Behavioral therapy + OAB medication	If LUTS remain obstructive → add α-blocker

→ Then reassess: Satisfaction?

• YES → Surveillance
• NO → Surgical therapy (= therapy failure — see Surgical Management — Indications and Surgical Choice)

Watchful Waiting & Lifestyle

• Offer to men with mild/moderate symptoms who are minimally bothered — bother-based, not score-based
• Offer lifestyle advice & self-care prior to, or concurrent with, treatment
• Components: education; reassurance (cancer is not the cause); reduced fluid intake at specific times; moderate caffeine; relaxed + double voiding; urethral milking for post-micturition dribble; distraction techniques; bladder retraining; medication review/re-timing (especially diuretics); treat constipation, control DM
• Efficacy: ~85% with mild LUTS stable at 1 year; 5-year failure 21% (79% clinically stable)
• Follow-up: 6 months, then annually — history, bladder diary, IPSS, uroflowmetry, PVR

Medical Management

α-Blockers

Drug	Selectivity	Key effect
Doxazosin	Non-selective	More hypotension
Terazosin	Non-selective	Hypotension
Alfuzosin	Non-selective	Hypotension
Tamsulosin	Selective α1A	Retrograde ejaculation
Silodosin	Selective α1A	Most retrograde ejaculation

• α1A receptors found in → prostate, bladder neck, distal ureter
• Silodosin → improvement in urinary flow within 8 h
• Tamsulosin → improvement within 24 h
• Alfuzosin → least retrograde ejaculation — < 1%
• All 5 are equally effective — IPSS improvement 4–7 points vs placebo
  • Switch α-blocker for side effects → worthwhile
  • Switch for insufficient response → not recommended — drug type doesn't change effectiveness

Choosing by side-effect profile

Concern	Prefer
Ejaculatory dysfunction	Alfuzosin, doxazosin, terazosin (no difference vs placebo) — avoid silodosin/tamsulosin in young sexually active men
Orthostatic hypotension / syncope	Alfuzosin, tamsulosin, silodosin
On sildenafil/vardenafil	Avoid terazosin & doxazosin (potentiate hypotension); tamsulosin 0.4 mg does not

• IFIS — Intraoperative Floppy Iris Syndrome
  • Tamsulosin has the highest risk — 40× alfuzosin; all α-blockers raise it somewhat
  • Ask about planned cataract surgery before starting; delay initiation until after
  • Stop tamsulosin 4–7 days pre-op is routine — doesn't fully eliminate the risk
  • 1 serious complication per 255 men on tamsulosin in the immediate pre-op window
• α-blocker for AUR → prescribe before a voiding trial; at least 3 days of therapy first
  • A successful trial still leaves them at increased risk of recurrent retention — say so
  • Delay the voiding trial if there's an active UTI

5α-Reductase Inhibitors (5-ARI)

Drug	Inhibits
Finasteride	Type 2
Dutasteride	Type 1 + 2

Indications to start a 5-ARI:

1. Prostate volume > 40 cc
2. PSA > 1.5

Effects:

• Reduce prostate size by 30%
• Improve symptom score by 30%
• Reduce risk of urinary retention by 50%
• Reduce need for surgical intervention by 50%
• Decrease PSA by 50% after 9 months → double the PSA for the actual result
• Help stop chronic hematuria related to the prostate (consider a 5-ARI to reduce intra-operative bleeding / transfusion before TURP)

PDE5 — Tadalafil

• Tadalafil 5 mg daily — discuss for LUTS/BPH irrespective of comorbid ED
• Mean IPSS drop 1.7 points; similar to tamsulosin 0.4 mg at 3 months
• Does NOT improve urodynamic profiles
• AEs: headache, nasopharyngitis, back pain

Combination Therapy

Combination	When
α-blocker + 5-ARI	Only with demonstrable enlargement — PV >40 cc / PSA >1.5
α-blocker + anticholinergic	Moderate–severe storage-predominant LUTS — check PVR before and during
α-blocker + β₃-agonist	Moderate–severe storage LUTS, esp. older patients where anticholinergics are inappropriate

Follow-up on Medical Therapy

• Reassess at 4–12 weeks: α-blocker / PDE5 / β₃ / anticholinergic → as early as 4 weeks; 5-ARI → wait 3–6 months
• Assess → adverse effects + IPSS (every visit); consider PVR & uroflow
• Reasonable trial length → 4 weeks (α-blocker or PDE5), 6–12 months (5-ARI)
• Failure → think detrusor underactivity (urodynamics clarifies), lack of efficacy, or LUTS not actually from BPH

Nocturnal Polyuria & Desmopressin

• Nocturnal polyuria = nocturnal output > 20% of 24-h output (young) or > 33% (age > 65)
• Age < 65 → start 0.1 mg/day, escalate weekly to max 0.4 mg/day
• Age > 65 with nocturia ≥ 2×/night → low dose only; do not use if serum Na is below normal (EAU: Weak)
• No fluids 1 h before and 8 h after dosing
• Na monitoring: baseline, day 3, day 7, 1 month, then periodically; if normal → every 3 months; more frequent if > 65; restart the sequence after any dose escalation
• Clinically significant hyponatremia → 11% in men ≥ 65 vs 0% in men < 65 (50 mcg)
• Exclude sleep apnea before prescribing

Trials

PLESS (Proscar Long-term Efficacy & Safety Study)

• Finasteride vs placebo
• → Improved symptom score, flow rate, decreased prostate volume
• → 50% reduction in AUR
• → 50% reduction in BPH surgery

CombAT (Combination therapy)

• Daily tamsulosin vs dutasteride vs placebo vs combination
• → Improved symptom score, flow rate, decreased prostate volume
• → Combination has the same effect on reducing AUR & surgery compared with dutasteride alone
• → More side effects with combination

MTOPS

• Placebo vs doxazosin vs finasteride vs combination
• → Dual therapy reduced progression significantly more than either drug alone
• → Finasteride & combination reduced risk of AUR & surgery
• → Reduce PSA 50% & volume

OAB & BPH

• 75% of men with BPH have OAB — due to the overworked bladder
• 19% have persistent OAB after surgical therapy
• Management discussed later in neuro-urology

Surgical Management — Indications

• Recurrent retention
• Recurrent infection
• Recurrent hematuria
• Renal insufficiency / hydronephrosis
• Therapy failure
• Bladder stones

Surgical Choice

Depends on → size · anticoagulation · preservation of ejaculation

By prostate size

Volume	Options
< 30 cc	TUIP, TURP, HoLEP, ThuLEP, PVP
30–80 cc	TURP, HoLEP, ThuLEP, PVP, Rezum, UroLift
> 80 cc	HoLEP, ThuLEP, simple prostatectomy

By special circumstance

Scenario	Choice
Anticoagulated, > 80 cc	HoLEP, ThuLEP
Anticoagulated, < 80 cc	PVP, HoLEP, ThuLEP
Wants to preserve erection & ejaculation	Rezum & UroLift

• Cannot do UroLift in a median-lobe prostate

Newer / Minimally Invasive Options

Technique	Size	EAU position
UroLift (PUL)	< 70 mL, no middle lobe	Strong — offer if preserving ejaculatory function
Aquablation	30–80 mL	Weak — alternative to TURP; Strong: counsel on bleeding risk & lack of long-term data
PAE	no size limit given	Weak — accept less optimal outcomes vs TURP; only with trained interventional radiology
Rezum (WVTT)	30–80 cc (AUA)	No EAU rating — narrative only
iTind	25–75 cc (AUA)	No EAU rating — under investigation

• Rezum can be used with a median lobe — an advantage over UroLift
• Rezum → 52% meaningful QoL response at 12 months; surgical retreatment 4.4% over 5 years
• iTind → device left in situ 5 days, then removed by outpatient urethroscopy; no new ejaculatory or erectile dysfunction reported

Mechanisms worth a line each

• UroLift (PUL) → transprostatic suture implants pull the urethral lumen toward the capsule — no tissue ablated; urethral side epithelializes within 12 months; PSA unchanged
• WVTT / Rezum → convective radiofrequency steam into the transition zone, denaturing the adenoma
• PVP / GreenLight → 532 nm side-firing, absorbed by hemoglobin; penetration 0.8 mm; saline → no TUR syndrome; use 120 W or 180 W (the 80 W platform had higher retreatment)
• HoLEP / ThuLEP → chromophore is water; penetration 0.4 mm holmium / 0.2 mm thulium → superficial + strongly coagulative = ideal for enucleation
• RWT / Aquablation → robotic waterjet with TRUS mapping, sparing the verumontanum; hemostasis afterwards by cautery/tamponade/traction
  • Not truly a MIST — requires general anesthesia
• TUMT → microwave heating to ≥ 45 °C → coagulation necrosis; higher retreatment than TURP; being displaced by newer MISTs

TURP

• Monopolar → glycine (hypotonic) → TUR syndrome
• Bipolar → normal saline (isotonic)
• Most common post-op complication → failure to void

Extravasation & perforation of the prostatic capsule

• → Abdominal distension
• Management:
  • Control bleeding & stop the procedure
  • Urethral catheter drainage

TUR Syndrome — (brain edema)

• Definition: Na < 125 + 2 symptoms

Symptoms

• Vomiting
• Bradycardia
• Chest pain
• Mental confusion
• Visual disturbance

Risk factors

• Monopolar
• Large prostate
• Long resection time > 90 min
• Capsular perforation
• Open vein
• Elevated height of irrigation fluid
• CHF or liver failure

Management

1. Stop TURP, 3-way Foley + CBI with NS
2. ABC, 100% O₂, vitals q2h, labs stat + q4h
3. Lasix 40 mg IV, 200 cc hypertonic 3% NS over 1–2 h — don't over-correct → osmotic demyelination
4. If seizures → Lorazepam 4–8 mg IV

Open Prostatectomy

Retropubic

• Excellent anatomic exposure
• DVC needs to be ligated

Suprapubic (= transvesical)

• Allows access to a large median lobe
• Good for bladder stones or symptomatic diverticulum

Post-operative Follow-up

• Review 4–6 weeks after catheter removal
• Assess → IPSS, uroflowmetry, erectile & ejaculatory function, PVR
• If symptomatic relief and no adverse events → no further re-assessment necessary