Optimising Assessment and Treatment Decisions for Men with BPH

Although recent guidelines for the management of benign prostatic hyperplasia (BPH) outline evaluation of men presenting with lower urinary tract symptoms (LUTS), absolute indications for those who require surgery, and guidance for those who are eligible for watchful waiting, they do not provide concrete guidance on how to select patients for medical versus surgical versus minimally invasive therapy (MIT). The choice of medical versus MIT or surgical therapy should be thoroughly discussed with patients and the magnitude and durability of benefits and adverse events individualised. MIT offers a genuine alternative to transurethral resection of the prostate for men who are comfortable with a lower degree of benefit and a less durable outcome but who see the benefit of the reduced long-term adverse events. For men wishing to avoid surgery, the α-blockers typically provide symptom relief within 1-2 wk of starting therapy, but they do not reduce the long-term risks of acute urinary retention (AUR) and BPH-related surgery. The 5α-reductase inhibitors act on the underlying disease by reducing prostate volume; treatment results in improvements in symptoms compared with placebo with an onset typically of 3-6 mo. In contrast with the α-blockers, they also significantly reduce the risk of AUR and BPH-related surgery and are therefore suitable for men with prostatic enlargement who wish to combine symptomatic benefits with a reduction in the risk of long-term outcomes.