Benign prostatic hyperplasia – Quick Reference

• This is a Quick Reference article. See also the main article Benign prostatic hyperplasia .

Examining the patient

• If the patient has difficulty passing urine, feeling of poor bladder emptying, or nocturia at least twice a night, ask him to fill in the IPSS questionnaire .
• DRE (digital rectal examination)
• Test for dipstick chemical urinalysis, creatinine, PSA.
• Determine residual urine volume and prostatic size by ultrasonography, if available (video ; pictures ).

Drug therapy

• Watchul waiting is sufficient, if the symptoms are mild (IPSS < 8).
• If the prostate size is < 30 ml and PSA is < 1.5 µg/l, first choice is an alpha-1 blocker: tamsulosin, alfuzosin, doxazosin or terazosin.
• If the prostate is clearly enlarged or PSA is > 1.5 µg/l, a 5-alpha-reductase inhibitor (finasteride or dutasteride) or an alpha-1 blocker can be used.
• The combination of an alpha blocker and a 5-alpha-reductase inhibitor relieves symptoms more efficiently than either drug alone.
• Phosphodiesterase 5 inhibitors are particularly suitable for patients suffering from mild to moderate urinary symptoms and who concomitantly are in need of treatment for erectile dysfunction.

Indications for referral to a urologist

• Age under 50 years
• Suspicious finding at palpation of the prostate (nodularity or a hard area)
• The following abnormalities in PSA concentrations:
  • PSA > 10 µg/l, or > 3 µg/l in patients under 65 years of age
  • PSA increase > 0.75 µg/l/year
  • Total PSA in the range 4–10 µg/l and free PSA fraction < 15 % of total PSA
• Urinary retention (first aid: suprapubic cystostomy [video ] or catheterization), overflow incontinence, or residual urine exceeding 400 ml despite drug therapy
• Pain associated with difficulty in urination
• Haematuria PSA &gt; 10 µg/l, or &gt; 3 µg/l in patients under 65 years of age PSA increase &gt; 0.4 µg/l/year Total PSA in the range 4&#x2013;10 µg/l and free PSA fraction &lt; 15 % of total PSA

Follow-up

• Inform the patient that he should contact the doctor if the symptoms get worse.
• Test for creatinine, PSA and (if indicated) residual urine at 6–12-month intervals. If creatinine is above upper normal limit, refer to a urologist. Note that finasteride halves the PSA level.
• PSA concentration should decrease during finasteride treatment.