Benign prostatic hyperplasia (BPH) is a histologic diagnosis that can produce benign prostatic enlargement → obstruction → lower-urinary-tract symptoms. The 2021 AUA guideline structures evaluation and a stepwise ladder from behavioral measures through medical therapy to a range of surgical options chosen largely by prostate size.
Background and Evaluation
- BPH → BPE → BPO: not every man with BPH develops enlargement, and not every man with enlargement develops obstruction; long-standing obstruction can cause hydroureteronephrosis and renal insufficiency. BPH requires testosterone (5α-reductase → DHT drives growth). BPE contributes to LUTS by a static (bulk) and a dynamic (smooth-muscle tone) component. Prevalence rises with age (~60% at 60, ~80% at 80).
- Recommended initial evaluation: history/physical, urinalysis, and IPSS (AUA-SI: 7 symptoms scored 0–5 + a QoL question; 0–7 mild, 8–19 moderate, 20–35 severe). The single most important history item is the patient's motivation for treatment. Optional: PVR (>300 mL worth monitoring; weak correlation with obstruction), uroflowmetry (≥150 cc voided; Qmax <10 mL/s has 70% specificity for BOO), and urodynamics (the most complete way to confirm BOO; consider with diagnostic uncertainty or catheter-dependent retention with a possibly underactive detrusor).
Medical Therapy
- Lifestyle/behavioral (first-line): limit fluids before bed/travel, caffeine/alcohol, and bladder irritants; avoid constipation; weight loss; timed and double voiding; pelvic-floor training.
- α-blockers (alfuzosin, doxazosin, silodosin, tamsulosin, terazosin) — all roughly equally effective (IPSS improvement 4–7 points). Switch for side effects, not for insufficient response. Avoid silodosin/tamsulosin in younger sexually active men (ejaculatory dysfunction; most with silodosin); prefer alfuzosin/tamsulosin/silodosin for orthostatic-hypotension risk; counsel re: IFIS and PDE5 interactions. For acute retention from BPH, start an α-blocker and complete ≥3 days before a voiding trial.
- 5-ARIs — finasteride (type 2; serum DHT ~70%) vs dutasteride (types 1+2; ~95%); reduce prostate size 15–25%, halve PSA (double the measured value after 1 year), and improve IPSS 3–4 points. Indicated to improve LUTS in demonstrably enlarged prostates (>30 cc, PSA >1.5 ng/dL, or palpable enlargement), to reduce progression/retention/surgery (PLESS), and for prostatic bleeding. Counsel on sexual side effects and the controversial association with prostate-cancer grade; slower onset than α-blockers.
- PDE5 (tadalafil 5 mg daily) — for LUTS/BPH irrespective of ED (IPSS ↓ ~1.7 points; no urodynamic improvement; do not combine with an α-blocker — no added benefit).
- Combinations: α-blocker + 5-ARI only for demonstrable enlargement (MTOPS/CombAT); α-blocker + antimuscarinic or + β3-agonist for predominant storage symptoms (monitor PVR; β3-agonist preferable in older patients where anticholinergics are avoided).
- Follow-up at 4–12 weeks (4 weeks for α-blockers/PDE5/β3/anticholinergics; 3–6 months for 5-ARIs) with AE review and IPSS.
Surgical Therapy
Indications: symptoms refractory to or intolerant of medical therapy, or complications — refractory retention, recurrent UTI, recurrent bladder stones, recalcitrant gross hematuria, renal insufficiency (GFR <60 for ≥3 months), or progressive bladder dysfunction. An asymptomatic diverticulum or elevated PVR alone is not an indication. Preoperatively, assess PVR (recommended) and consider prostate size/shape, uroflow, pressure-flow studies, and PSA; counsel on treatment failure and sexual (ejaculatory) side effects.
- TURP — the historical standard. Bipolar uses 0.9% saline (eliminating TUR syndrome) and allows longer resection for larger glands; monopolar uses iso-osmolar glycine/sorbitol/mannitol.
- TUIP — for prostates ≤30 cc; preserves ejaculation; higher retreatment than TURP.
- Photoselective vaporization (PVP/GreenLight) — 532 nm laser absorbed by hemoglobin (penetration 0.8 mm); saline irrigation; use 120 W or 180 W platforms.
- Simple prostatectomy (open/lap/robotic) — for large–very large glands.
- Prostatic urethral lift (UroLift) — transprostatic implants widen the lumen without ablation; for 30–80 cc prostates without an obstructive middle lobe; preserves erectile/ejaculatory function; no PSA change.
- Water vapor thermal therapy (Rezum) — convective steam ablates the transition zone; for 30–80 cc; preserves sexual function.
- Laser enucleation (HoLEP/ThuLEP) — prostate-size-independent; outcomes similar to TURP.
- Others: transurethral vaporization (bipolar TUVP), microwave therapy (TUMT; higher retreatment), aquablation/robotic waterjet (30–80 cc, general anesthesia). Not recommended: transurethral needle ablation and prostate-artery embolization (outside trials).
| Prostate size | Surgical options |
|---|---|
| Small (<30 g) | TUIP, TURP, PVP, TUVP, TUMT, laser enucleation |
| Average (30–80 g) | TURP, PVP, TUVP, TUMT, laser enucleation, WVTT, RWT, PUL |
| Large (>80–150 g) / very large (>150 g) | Simple prostatectomy, laser enucleation |
Sexual-function preservation: PUL and WVTT are preferred. Bleeding risk: PVP and laser enucleation are preferred (laser if anticoagulation cannot be stopped).
Self-Test
1. What are the recommended investigations for LUTS attributed to BPH? History/physical, urinalysis, and IPSS (optional: PVR, uroflowmetry, urodynamics).
2. Which α-blockers reduce the risk of ejaculatory dysfunction? Alfuzosin, doxazosin, terazosin (silodosin and tamsulosin cause the most).
3. Which α-blockers help with concomitant hypertension? Terazosin and doxazosin (non-specific α1-blockers approved for HTN and BPH).
4. Which α-blockers should be avoided in a man on sildenafil? Terazosin and doxazosin (their hypotensive effects are potentiated; tamsulosin 0.4 mg is not).
5. Surgical options for a ~50 g prostate? TURP, PVP, TUVP, TUMT, laser enucleation (HoLEP/ThuLEP), WVTT, RWT, PUL.
6. Which options best preserve erectile/ejaculatory function? Prostatic urethral lift (PUL) and water vapor thermal therapy (WVTT).