Physicians debate best management strategy for patient with benign prostatic hyperplasia

In the Annals of Internal Medicine, a general internal medicine physician and a urologist discuss treatment plans for benign prostatic hyperplasia (BPH) and how they would apply their recommendations to a patient who wishes to learn more about his options.

Lower urinary tract symptoms due to BPH are common among older patients assigned male sex at birth, regardless of gender identity. As many as 80% of patients 70 years of age and older are symptomatic. In 2021, the American Urological Association (AUA) published guidelines on the initial evaluation and medical management of lower urinary tract symptoms attributed to BPH and a separate guideline on surgical management. The AUA recommends pharmacologic interventions as a first-line treatment, and recommends surgery for patients who develop chronic kidney disease, refractory urinary retention, or recurrent urinary tract infections, and in those who do not respond to medical therapy.

BIDMC Grand Grounds experts C. Christopher Smith, MD, an internal medicine physician, an associate professor of medicine at Harvard Medical School, and a member of the Division of General Medicine at BIDMC, and Ajay Singla, MD, a urologist, lecturer on surgery at Harvard Medical School and director of the Center for Pelvic Floor Disorder, Neuro-Urology & Urodynamics in the Division of Urology at BIDMC recently debated the case of a 64-year-old man with one decade of lower urinary tract symptoms (LUTS) and a diagnosis for BPH. The patient has had no diagnostic testing to date and wishes to explore other treatment options.

In their assessment, both Drs. Smith and Singla agree with the AUA that for most patients, alpha-blockers should be the medications of first choice. Dr. Smith recommends the use of a validated symptom scoring index, such as the IPSS, but does not feel the score is necessary in order to establish a diagnosis of BPH. However, Dr. Singla advises deriving the IPSS for all patients with LUTS. Dr. Smith prefers to refer patients to urology for whom medical therapy has been ineffective and agrees with the other indications for referral as recommended by the AUA. Dr. Singla considers a transurethral resection of prostate (TURP) to be the gold standard procedure for patients who meet Dr. Smith's criteria for a urology referral.