BPH Management
On this page
Direct answer
A man with moderate-to-severe lower urinary tract symptoms from benign prostatic hyperplasia starts with an alpha-blocker, which works within days; a 5-alpha-reductase inhibitor is added — or started alone — when the prostate exceeds about 30 to 40 mL, shrinking the gland 20 to 25 per cent over six to twelve months and cutting the risk of retention and surgery. Surgery is reserved for drug failure or the absolute indications: refractory retention, recurrent infections or haematuria, bladder stones, and renal impairment. TURP remains the reference operation; holmium laser enucleation (HoLEP) matches it at any prostate size with less bleeding and shorter catheter time, at the cost of a steep learning curve.
What you must remember
- Baseline assessment set: IPSS score, uroflowmetry with Qmax, post-void residual, prostate volume and PSA — the five numbers every follow-up is judged against.
- Alpha-blockers: tamsulosin 0.4 mg, silodosin or alfuzosin relieve symptoms within days but do not prevent progression; first-dose hypotension is why the dose is taken at bedtime.
- Intraoperative floppy iris syndrome: tamsulosin, more than alfuzosin, wrecks cataract surgery — every patient must be told to inform the ophthalmologist; a recurring exam stem in itself.
- 5-alpha-reductase inhibitors: finasteride or dutasteride shrink the gland 20 to 25 per cent over 6 to 12 months, reduce retention and surgery (MTOPS, CombAT), and halve serum PSA — double the value when interpreting screening.
- Tadalafil 5 mg daily is the single agent licensed for both erectile dysfunction and LUTS — the scripted answer for the man who has both.
- Absolute indications for surgery: refractory retention after a failed trial without catheter, recurrent urinary infections, bladder stones, renal impairment from obstruction, refractory gross haematuria.
- TURP facts: retrograde ejaculation in roughly 65 to 75 per cent (consent essential); monopolar glycine irrigation risks the TUR syndrome, bipolar saline nearly abolishes it.
- Laser choices: HoLEP for any size including prostates over 100 g; photovaporisation (GreenLight) suits patients who cannot stop anticoagulants.
One patient from prescription to theatre
A 68-year-old presents with IPSS 19, prostate 55 mL, Qmax 8 mL/s, residual 120 mL, PSA 3.1. Start tamsulosin 0.4 mg at night — relief within a week — and add dutasteride, because a 55 mL gland is exactly what shrinks under 5-alpha-reductase blockade; counsel him that the second drug needs six months to show its effect and that combination therapy reduced clinical progression in MTOPS. Two years later he retains after a long journey; catheterised, he returns for a trial without catheter after two to three days of alpha-blocker cover — which genuinely improves trial success — and fails. That failure is an absolute indication. Now the operation: at 55 mL, bipolar TURP is straightforward; had he been on clopidogrel that cardiac disease forbids stopping, HoLEP or GreenLight vapourisation would be chosen for their haemostasis; had the gland been 120 g, HoLEP with morcellation replaces the open simple prostatectomy of an older generation. Consent covers retrograde ejaculation.
How the exam frames it
The recurring stems are pharmacological traps. "Best initial drug for IPSS 16 with prostate 25 mL" — alpha-blocker, because a small gland does not respond to finasteride. "A patient on tamsulosin undergoes cataract surgery" — intraoperative floppy iris syndrome, and the examiner wants the phrase told to the ophthalmologist in advance. "PSA 1.8 after two years of finasteride" — interpret as roughly 3.6, never as reassurance. "A man with urgency, frequency and residual 220 mL" — the antimuscarinic is the wrong answer; relieve the obstruction first. And the surgical stem: "confusion, bradycardia and hyponatraemia forty minutes into monopolar TURP" — the TUR syndrome from glycine absorption; visual disturbance from glycine is the well-known clue.
Frequently asked questions
What is the first-line drug for moderate BPH symptoms?
An alpha-blocker such as tamsulosin 0.4 mg nightly, which improves symptoms within days regardless of prostate size. Add a 5-alpha-reductase inhibitor when the gland exceeds 30 to 40 mL; monotherapy suits men with large glands and intolerable alpha-blocker side effects, accruing over 6 to 12 months.
Which single drug suits a man with both erectile dysfunction and BPH?
Tadalafil 5 mg once daily, licensed for both conditions. All other BPH drugs do nothing for erectile function, and alpha-blockers can worsen ejaculation.
List the absolute indications for surgical treatment of BPH.
Refractory urinary retention after a failed trial without catheter, recurrent urinary tract infections or gross haematuria attributable to the prostate, bladder stones, and renal impairment secondary to obstruction. Failed medical therapy is the relative indication.
What is TUR syndrome and how is it managed?
Dilutional hyponatraemia from absorption of hypotonic glycine irrigation during monopolar TURP, with bradycardia, confusion and visual disturbances. Stop the resection, give diuretics, and use hypertonic saline for severe symptomatic hyponatraemia; bipolar resection in saline prevents it.
Which operation suits a prostate of 120 grams?
HoLEP — enucleation with morcellation — achieving size-independent results with less bleeding and shorter catheterisation than TURP or open simple prostatectomy, though it demands trained hands. Open prostatectomy survives only where laser expertise is unavailable.