Regarding Benign Prostatic Hyperplasia

A 62-year-old man presents with nocturia, hesitancy and terminal dribbling. Prostate examination reveals a moderately enlarged prostate with no irregular features and a well defined median sulcus. Blood tests show: PSA 1.3 ng/ml What is the most appropriate management?
A. Alpha-1 antagonist
B. 5 alpha-reductase inhibitor
C. Non-urgent referral for transurethral resection of prostate
D. Empirical treatment with ciprofloxacin for 2 weeks
E. Urgent referral to urology

Answer:
A. Alpha-1 antagonist

Discussion: Alpha-1 antagonists are first-line in patients with benign prostatic hyperplasia

Benign prostatic hyperplasia  is a common condition seen in older men.

Risk factors include:

• age: around 50% of 50-year-old men will have evidence of BPH and 30% will have symptoms. Around 80% of 80-year-old men have evidence of BPH
• ethnicity: black > white > Asian

Clinical Features: BPH typically presents with lower urinary tract symptoms (LUTS), which may be categorised into: 

 voiding symptoms (obstructive): weak or intermittent urinary flow, straining, hesitancy, terminal dribbling and incomplete emptying 

 storage symptoms (irritative) urgency, frequency, urgency incontinence and nocturia 

 post-micturition: dribbling 

 complications: urinary tract infection, retention, obstructive uropathy 

Management options include:

• watchful waiting 
• medication: alpha-1 antagonists, 5 alpha-reductase inhibitors.
• surgery: transurethral resection of prostate (TURP) 

Alpha-1 antagonists e.g. tamsulosin, alfuzosin 

 decrease smooth muscle tone (prostate and bladder) 

 considered first-line, improve symptoms in around 70% of men 

 adverse effects: dizziness, postural hypotension, dry mouth, depression 

5 alpha-reductase inhibitors e.g. finasteride 

 block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH  unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease progression. This however takes time and symptoms may not improve for 6 months. They may also decrease PSA concentrations by up to 50% 

 adverse effects: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia