Medical management of LUTS due to benign prostatic hyperplasia: AUA Guideline

Key recommendations of the guideline are given below

Evaluation

• In the initial evaluation of patients presenting with bothersome LUTS possibly attributed to BPH, clinicians should obtain a medical history, conduct a physical examination, utilize the International Prostate Symptom Score (IPSS), and perform a urinalysis.
• Patients should be counseled on options for intervention, which can include behavioral/lifestyle modifications, medical therapy and/or referral for discussion of procedural options.
• Patients should be evaluated by their providers 4-12 weeks after initiating treatment (provided adverse events do not require earlier consultation) to assess response to therapy. Revaluation should include the IPSS. Further evaluation may include a post-void residual (PVR) and uroflowmetry.
• Patients with bothersome LUTS/BPH who elect initial medical management and do not have symptom improvement and/or experience intolerable side effects should undergo further evaluation and consideration of the change in medical management or surgical intervention.

Medical therapy

• Clinicians should offer one of the following alpha blockers as a treatment option for patients with bothersome, moderate to severe LUTS/BPH: alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin.
• When prescribing an alpha blocker for the treatment of LUTS/BPH, the choice of alpha blocker should be based on patient age and comorbidities, and different adverse event profiles (eg, ejaculatory dysfunction [EjD], changes in blood pressure).
• When initiating alpha blocker therapy, patients with planned cataract surgery should be informed of the associated risks and be advised to discuss these risks with their ophthalmologists.
• For the purpose of symptom improvement, 5-alpha reductase inhibitor (5-ARI) monotherapy should be used as a treatment option in patients with LUTS/BPH with prostatic enlargement as judged by a prostate volume of >30cc on imaging, a prostate-specific antigen (PSA) > 1.5ng/dL, or palpable prostate enlargement on digital rectal exam (DRE).
• 5-ARIs alone or in combination with alpha-blockers are recommended as a treatment option to prevent the progression of LUTS/BPH and/or reduce the risks of urinary retention and need for future prostate-related surgery.
• Before starting a 5-ARI, clinicians should inform patients of the risks of sexual side effects, certain uncommon physical side effects, and the low risk of prostate cancer.
• Clinicians may consider 5-ARIs as a treatment option to reduce intraoperative bleeding and peri- or postoperative need for blood transfusion after transurethral resection of the prostate (TURP) or other surgical intervention for BPH.
• For patients with LUTS/BPH irrespective of comorbid erectile dysfunction (ED), 5mg daily tadalafil should be discussed as a treatment option.
• 5-ARI in combination with an alpha-blocker should be offered as a treatment option only to patients with LUTS associated with demonstrable prostatic enlargement as judged by a prostate volume of >30cc on imaging, a PSA >1.5ng/dL, or palpable prostate enlargement on DRE.
• Anticholinergic agents, alone or in combination with an alpha-blocker, may be offered as a treatment option to patients with moderate to severe predominant storage LUTS.
• Beta-3-agonists in combination with an alpha-blocker may be offered as a treatment option to patients with moderate to severe predominant storage LUTS.
• Clinicians should not offer the combination of low-dose daily 5mg tadalafil with alpha-blockers for the treatment of LUTS/BPH as it offers no advantages in symptom improvement over either agent alone.
• Physicians should prescribe an oral alpha-blocker prior to a voiding trial to treat patients with AUR related to BPH.
• Patients newly treated for AUR with alpha-blockers should complete at least three days of medical therapy prior to attempting trial without a catheter (TWOC).
• Clinicians should inform patients who pass a successful TWOC for AUR from BPH that they remain at increased risk for recurrent urinary retention.