Managing the Lower Urinary Tract Symptoms of BPH: New Guidance

Neil Skolnik, MD


January 20, 2022

This transcript has been edited for clarity.

I'm Dr Neil Skolnik. Today, I'm going to talk about the American Urologic Association's new guidelines on the management of lower urinary tract symptoms, also called LUTS, due to benign prostatic hyperplasia (BPH). BPH is common, occurring in about 60% of men over 60 years of age. BPH causes symptoms through two mechanisms. The first is hypertrophy, leading to resistance to urinary outflow and symptoms of hesitancy; difficulty starting a stream; and a slow, weak stream of urine. The second is increased smooth muscle tone of the urethra and bladder, which leads to symptoms like urgency, frequency, and nocturia.

During initial evaluation, the guidelines recommend quantifying symptoms using an International Prostate Symptom Score, which can then be used to follow symptoms. Do a physical exam, examine the prostate, and obtain a urinalysis. A postvoid residual is considered optional. For mild symptoms, simply limit fluid intake prior to bedtime or travel. Avoid diuretics if possible, decrease caffeine and alcohol intake, and weight loss and exercise can actually help. The guidelines are clear that they do not examine alternative therapies other than to say that saw palmetto doesn't work as shown in randomized trials.

Let's now go on to pharmacologic therapy. Alpha-blockers are a good first choice. All of the alpha-blockers have about equal efficacy, but they have different side effects. Terazosin and doxazosin can cause orthostatic hypotension; tamsulosin and silodosin have the highest likelihood of causing ejaculatory dysfunction; and alfuzosin has the lowest incidence of ejaculatory dysfunction.

Next, we think about prostate size. If someone has an enlarged prostate, defined as > 30 grams on rectal exam or imaging or reflected by a prostate-specific antigen (PSA) level > 1.5 ng/dL, then a 5-alpha reductase inhibitor, such as finasteride or dutasteride, either alone or in combination with an alpha-blocker is recommended. The 5-alpha reductase inhibitors decrease the size of the prostate by about 25% over 6 months, meaning that it can take 6 or more months for it to have its effect on symptoms. Also, it can decrease the PSA by about 50%. Why is that important to recognize? Because if we choose to use PSA for screening for prostate cancer, the PSA has to be doubled in the assessment of prostate cancer risk in people who are on 5-alpha reductase inhibitors. These agents reduce the need for future prostate surgery and decrease the likelihood of future urinary retention.

It's worth reading a little bit about the relationship between the 5-alpha reductase inhibitors and cancer risk. Potentially, based on the CombAT study, they can lead to a decrease in the incidence of low- and high-grade prostate cancers. But be aware that some studies have raised the possibility that they increase the rate of high-grade prostate cancers.

The next class of agents we'll talk about is the phosphodiesterase 5 (PDE-5) inhibitors that we're aware of from their effect on erectile dysfunction, such as tadalafil. Tadalafil decreases symptoms in men, whether or not they have erectile dysfunction, and it has about equal efficacy as alpha-blockers. It has no additive efficacy, however, when combined with an alpha-blocker.

For men with severe storage symptoms (urinary urgency and frequency), an anticholinergic such as tolterodine or oxybutynin can be used either alone or in combination with an alpha-blocker. The guidelines note that the rate of urinary retention is low (about 1%) but a postvoid residual should be obtained if using an anticholinergic drug.

Another option here is the beta-3 agonist mirabegron, which can be added to alpha-blockers for persistent storage symptoms. It's not recommended to be used alone. It does not cause urinary retention and so therefore might be a particularly good option for older patients in whom we want to avoid anticholinergic therapy.

In summary, if LUTS symptoms are bothersome and pharmacologic treatment is needed, start with an alpha-blocker. Consider adding a 5-alpha reductase inhibitor if the prostate is large. A 5-alpha reductase inhibitor can be used alone for an enlarged prostate, but it takes a while to kick in. Alternatively, you can start with tadalafil, which might not be a bad option in men who also have erectile dysfunction. For men with symptoms of frequency and urgency, an anticholinergic agent can be used alone or added to an alpha-blocker or a beta-3 agonist can be added to an alpha-blocker.

This is a lot of important information for something we see frequently in the office. I'm Dr Neil Skolnik, and this is Medscape.

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