Benign prostatic hyperplasia: When to treat - and how

The goal of care for patients with benign prostatic hyperplasia (BPH) has changed from reduction of prostate size and outlet obstruction to minimization of bothersome symptoms. Watchful waiting may be appropriate for many patients with mild complaints. The International Prostate Symptom Score questionnaire can help track symptoms quantitatively over time and facilitate the choice of therapy. α-Adrenergic blockade is considered firstline treatment, regardless of symptom severity or baseline prostate volume. Terazosin or doxazosin is initiated at low dosages and titrated upward. Tamsulosin relieves symptoms quickly without lowering blood pressure. The 5α-reductase inhibitors finasteride and dutasteride are well tolerated and do not require dose titration, but 6 to 12 months of therapy may be necessary for full effectiveness. Referral to a urologist is appropriate when symptoms do not respond to medical therapy, complications arise, or the patient initially presents with complicated BPH.