Benign Prostatic Hyperplasia

Page updated Winter 2023.

Disclaimer: Medicine is an ever-changing science.  We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable sources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to take or administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original sources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.

Medical Treatment of BPH


For dose of medications click here. 

α1-blockers 

Will be offered to men to with moderate-to-severe lower urinary tract symptoms (LUTS).

Currently available medications are: Tamsulosin, Silodosin, Terazosin, Doxazosin, and Alfuzosin.


5α-reductase Inhibitors

Will be offered to men to with moderate-to-severe LUTS and a prostate volume > 40 mL.

Onset of action will be delayed for three to six months.

Currently available medications are: Finasteride and Dutasteride.



Muscarinic Receptor Antagonists

Will be offered to men with moderate-to-severe LUTS who mainly have bladder storage symptoms.

Will not be offered if PVR > 150 mL.

Currently available medications are:

Oxybutynin, Tolterodine,  Fesoterodine, Solifenacin,  Darifenacin, Propiverine, and Trospium.


Phosphodiesterase Type 5 Inhibitors

Will be offered to men with moderate-to-severe LUTS with or without erectile dysfunction.

Currently available medications for this purpose: Tadalafil



Beta-3 Agonists

Will be offered to men with moderate-to-severe LUTS who mainly have bladder storage symptoms.

Currently available medications: Mirabegron 



α1 locker + a 5α-reductase Inhibitor 


May be offered to men with moderate-to-severe LUTS and a prostate volume > 40 mL.



α1-blocker+ Muscarinic Receptor Antagonist


May be offered to men with moderate-to-severe LUTS if relief of storage symptoms has been insufficient with monotherapy with either drug.



Desmopressin



We may offer desmopressin to men men < 65 years who have nocturia due to nocturnal polyuria.


We may offer low dose desmopressin to men men > 65 years who have nocturia due to nocturnal polyuria.


Patients should avoid drinking fluids at least one hour before and eight hours after dosing. 


Patient needs to be screened for hyponatremia at baseline, day three and day seven, one month after initiating therapy, and periodically during treatment. Na needs to be checked more frequently in high risk patients and in men > 65.

Indications for Surgery

Lower urinary tract symptoms due to BPH refractory to other therapies


Refractory urinary retention secondary to BPH


Renal insufficiency secondary to BPH

 

Recurrent urinary tract infections 


Recurrent bladder stones 


Gross hematuria due to BPH

Pressure Flow Study 

Pressure flow study is suggested before invasive treatments in the following situations:

Open,  or Robotic Prostatectomy 

If prostate size > 80 mL

TURP

Monopolar or bipolar TURP; if prostate is 30-80 mL. We may consider preoperative Finasteride to reduce intraoperative bleeding.

Needs general anesthesia.

Hospital stay: 0–2 days

Catheterization: 1–3 days

Adverse Events (per literature):

Monopolar TURP Setting

Cut: 80 to 100 W

Coag: 50 to 70W

Irrigation:  Glycine or Sorbitol  

Bipolar TURP  Setting

Cut: 200

Coag:100

Irrigation: Saline

TURP Supplies

Standard 21 and 22 F Cystoscope Set

Resectoscope (Monopolar or Bipolar) set

TUR Loop

Lens: 30 degrees

Light source, Cable, Camera

Irrigation Bags, and Tubing

Glass Ellik Bladder Evacuator


Lubricant

 

10 Syringes

 

3 Way Foley Catheter

 

Sloan PP-300 - PROTECTORS, PANT

Additional Supplies for Urethral Stricture

Van Buren Sounds

Urethral Dilator Set- COOK MEDICAL

AMPLATZ 0.038 Guidewire

22 French Urethrotome Set


Straight Collins Cold Knife


Green Light HPS laser PVP


This technique is a viable surgical option for BPH irrespective of prostate volume. 

A recent study of men with prostate sizes of 80-150 gram showed PVP had a retreatment rate of 27% at three years of follow-up. 

The advantage of the current PVP technology is the combined vaporization and coagulation.


OR Supplies and settings:


Machine: Greenlight XPS


Fiber: Boston Scientific LUQUID COOLED 180 W


Our preferred setting at beginning:

Vapor: 80

Coag: 35


Our preferred setting later:

Vapor: 120

Coag: 35

Lens: 30 degrees

Irrigation:

Hang four 3 liters 0.9% Saline bags for irrigation

Hang one 1-liter Saline bags for cooling

Light source and cable

Camera

Laser Eye Protection Glasses

Sloan PP-300 - PROTECTORS, PANT

Standard 21 and 22 Cystoscope Set

Bugbee Electrode

Standard TURP set

Sterile Water Irrigation Bags- if Bugbee, or Monopolar TURP are used

Glass Ellik Bladder Evacuator

Additional Supplies for Urethral Stricture

Van Buren Sounds

Urethral Dilator Set- COOK MEDICAL

AMPLATZ 0.038 Guidewire

22 French Urethrotome Set


Straight Collins Cold Knife


Laser Enucleation


Holmium laser or  thulium laser; size-independent 


PUL


Prostatic Urethral Lift; If  prostate size <80 mL and no obstructive middle lobe


TUMT

Transurethral Microwave Therapy ;If prostate size <80 mL and no obstructive middle lobe


Water Vapor Thermal Therapy


If prostate size <80 mL


Aquablation


For patients with prostate size of 30-80 mL


TUIP

If prostate size <30 mL

TUVP

Bipolar; if prostate size is 30-80 mL