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Treatment Algorithm for Benign Prostatic Hyperplasia (BPH)

• Benign prostatic hyperplasia (1/6): definitions, epidemiology and etiology
• Benign prostatic hyperplasia (2/6): signs and symptoms
• Benign prostatic hyperplasia (3/6): diagnosis
• Benign prostatic hyperplasia (4/6): treatment algorithm
• Benign prostatic hyperplasia (5/6): medical treatment
• Benign prostatic hyperplasia (6/6): surgical treatment

Review literature: (Burnett und Wein, 2006) (DGU-Guideline: diagnostic workup, 2009) (DGU-Guideline: treatment, 2009) (EAU-Guideline: Oelke et al., 2010)

Absolute Indications for Surgical Treatment of BPH

• Postrenal kidney failure
• Recurrent urinary retention
• Recurrent urinary tract infections
• Recurrent hematuria
• Huge bladder diverticula

Surgical Treatment Options:

• TURP (up to 75 ml prostate volume)
• Open prostatectomy (over 75 ml prostate volume)
• If the treatment of bladder diverticula or removal of bladder stones is necessary, an open prostatectomy may be useful even with a smaller prostate volume.
• Alternative techniques: Greenlight laser treatment or HoLEP

Medical Treatment for BPH:

BPH medication is indicated for significant and disturbing symptoms and if there are not absolute indications for surgical therapy present (see above). The following drug classes for the treatment of BPH are available, some drugs may be combined:

• Herbal extracts
• Alpha blocker
• 5α-reductase inhibitors
• Anticholinergics

Watchful waiting in BPH

Watchful waiting in BPH is possible, if there is no need for surgery and the patient accepts his (moderate) symptoms. 40% of the patients initially assigned to watchful waiting experience improvement of symptoms. 10–27% of the patients are going to have surgery for disease progression, risk factors are prostate volume (>40 ml), PSA concentration (>3.2 mg/ml), and a high IPSS.

Algorithm for Initial Diagnosis and Treatment of Men with LUTS due to BPH

Fig. diagnostic workup of LUTS: algorithm for diagnosis and treatment of BPH at initial presentation, in accordance to the guidelines of the AUA 2003 [Kaplan, 2004a], DGU 2009 (DGU Guideline: diagnostic workup, 2009) (DGU-guideline: treatment, 2009) and EAU 2010 (Oelke et al., 2010):
(*) Despite adequate medical therapy.
(**) Urodynamics should be considered in men under 50 years, in patients over 80 years, more than 300 ml residual urine, maximum urinary flow >15 ml/s, suspected neurogenic lower urinary tract dysfunction, after radical pelvic surgery, after unsuccessful non-invasive therapy.
(***) Not an option after urinary retention or hematuria.

References

  Deutsche Version: Therapie der benignen Prostatahyperplasie