What are the key considerations for managing benign prostatic hyperplasia in older men?

Key considerations for the management of benign prostatic hyperplasia (BPH) in older men include:

• Initial assessment: Exclude serious underlying causes of lower urinary tract symptoms (LUTS) and manage treatable causes. Conduct a thorough medical history, physical examination including digital rectal exam, urine dipstick, and consider PSA testing if indicated by symptoms or prostate abnormalities. Assess symptom severity using tools like the International Prostate Symptom Score (IPSS) ².
• Lifestyle advice and self-management: Offer lifestyle interventions such as reducing fluid intake at inconvenient times, treating constipation, weight reduction, smoking cessation, and moderating caffeine and alcohol intake. Self-management can significantly reduce symptom severity and improve quality of life ¹.
• Active surveillance versus intervention: Discuss with men the options of active surveillance (reassurance and lifestyle advice with regular follow-up) or active intervention (drug treatment or surgery) based on symptom severity and impact on quality of life ¹,².
• Drug treatment: Offer drug treatment to men with bothersome LUTS when conservative management is unsuccessful or inappropriate. Alpha-blockers (alfuzosin, doxazosin, tamsulosin, terazosin) are recommended for moderate to severe symptoms (IPSS ≥8) ¹,².
• 5-alpha reductase inhibitors: Consider offering these (dutasteride or finasteride) to men with prostate estimated >30 g or PSA >1.4 ng/ml who are at high risk of progression, often in combination with alpha-blockers for moderate to severe symptoms ¹,².
• Additional pharmacological options: For persistent storage symptoms after alpha-blocker treatment, consider adding antimuscarinic drugs or mirabegron if antimuscarinics are contraindicated or not tolerated ¹,².
• Regular review: Review men on alpha-blockers at 4–6 weeks after initiation and then every 6–12 months, reassessing symptoms, quality of life, and adverse effects. Similarly, review men on 5-alpha reductase inhibitors at 3–6 months and then every 6–12 months ¹,².
• Referral and surgery: Refer men for specialist urological assessment if drug treatment fails or symptoms are severe. Surgical options include transurethral resection of the prostate (TURP), transurethral vaporisation, holmium laser enucleation, and others, with choice depending on prostate size and patient factors ¹,².
• Catheterisation: Consider intermittent or indwelling catheterisation in men with chronic urinary retention before surgery, or as long-term management if surgery is unsuitable ².
• Information and support: Provide men with access to information, support groups, and containment products if needed, involving carers where appropriate ¹,².