Benign prostatic hyperplasia

Red Flags

Acute urinary retention with renal impairment, infection, or significant distress — same-day catheterisation; investigate cause; trial without catheter on alpha-blocker^[1]
Macroscopic haematuria, suspected prostate cancer (raised PSA, abnormal DRE), or weight loss — separate cancer pathway^[1]
Recurrent UTI, bladder stones, refractory retention, hydronephrosis, or persistent residual >300 mL — surgical indication^[1]
Severe LUTS with renal impairment or acute on chronic retention — admit; avoid rapid decompression (post-obstructive diuresis); urology^[1]

First-line treatment

Interventions

Watchful waiting + lifestyle for mild symptoms^[1]
Reduce evening fluids, avoid caffeine and alcohol after evening, double voiding, bladder retraining, manage constipation; effective for IPSS ≤7
Combination medical therapy for moderate-severe symptoms^[1]
Alpha-blocker for symptom relief; add 5-alpha-reductase inhibitor for prostates >30 mL or PSA >1.5 (slower progression, reduces retention/surgery); add antimuscarinic or beta-3 agonist for OAB component
Minimally invasive surgical therapy (MIST)^[1]
Prostatic urethral lift (UroLift) — favours sexual function; water vapour thermal therapy (Rezum); aquablation; Optilume; outpatient or short-stay; selected based on prostate size and anatomy
Standard surgical procedures^[1]
TURP — gold standard for prostates 30–80 mL. Holmium laser enucleation (HoLEP) — size-independent, lower bleeding. Photoselective vaporisation (GreenLight) — useful in anticoagulated. Simple prostatectomy (open or robotic) — large prostates >80–100 mL

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Tamsulosin or silodosin (alpha-blocker)^[1]	Selective alpha-1A adrenergic blocker	Tamsulosin 0.4 mg PO daily; silodosin 8 mg PO daily	—	First-line symptomatic; rapid onset (days–weeks); orthostatic hypotension; intraoperative floppy iris syndrome — inform ophthalmologist before cataract surgery
Finasteride or dutasteride (5-ARI)^[1]	5-alpha-reductase inhibitor	Finasteride 5 mg PO daily; dutasteride 0.5 mg PO daily	—	Add to alpha-blocker for prostate >30 mL or PSA >1.5; takes 6–12 months for full effect; reduces PSA by ~50% (interpret cancer screening accordingly); sexual side effects; teratogen — avoid handling crushed tablets in pregnancy
Combination alpha-blocker + 5-ARI (Combodart, Jalyn)^[1]	Combination	Tamsulosin 0.4 mg + dutasteride 0.5 mg PO daily	—	Convenient single-pill combination; CombAT trial showed superior symptom and progression outcomes
Tadalafil 5 mg (LUTS + ED)^[1]	PDE5 inhibitor	5 mg PO once daily	—	Daily-dose tadalafil approved for combined LUTS and ED; do not combine with nitrates; useful when sexual function preservation prioritised
Antimuscarinic (solifenacin, tolterodine) for OAB component^[1]	Muscarinic antagonist	Solifenacin 5–10 mg PO daily; tolterodine ER 4 mg PO daily	—	Add for OAB symptoms (urgency, frequency, nocturia) when residual urine acceptable; check PVR before adding (caution if >150 mL); dry mouth, constipation
Mirabegron (beta-3 agonist) for OAB component^[1]	Beta-3 agonist	25–50 mg PO daily	—	Alternative to antimuscarinic; lower dry mouth burden; BP elevation; less anticholinergic side effects

Tamsulosin or silodosin (alpha-blocker)^[1]

Selective alpha-1A adrenergic blocker

Adult: Tamsulosin 0.4 mg PO daily; silodosin 8 mg PO daily
Paediatric: —

First-line symptomatic; rapid onset (days–weeks); orthostatic hypotension; intraoperative floppy iris syndrome — inform ophthalmologist before cataract surgery

Finasteride or dutasteride (5-ARI)^[1]

5-alpha-reductase inhibitor

Adult: Finasteride 5 mg PO daily; dutasteride 0.5 mg PO daily
Paediatric: —

Add to alpha-blocker for prostate >30 mL or PSA >1.5; takes 6–12 months for full effect; reduces PSA by ~50% (interpret cancer screening accordingly); sexual side effects; teratogen — avoid handling crushed tablets in pregnancy

Combination alpha-blocker + 5-ARI (Combodart, Jalyn)^[1]

Combination

Adult: Tamsulosin 0.4 mg + dutasteride 0.5 mg PO daily
Paediatric: —

Convenient single-pill combination; CombAT trial showed superior symptom and progression outcomes

Tadalafil 5 mg (LUTS + ED)^[1]

PDE5 inhibitor

Adult: 5 mg PO once daily
Paediatric: —

Daily-dose tadalafil approved for combined LUTS and ED; do not combine with nitrates; useful when sexual function preservation prioritised

Antimuscarinic (solifenacin, tolterodine) for OAB component^[1]

Muscarinic antagonist

Adult: Solifenacin 5–10 mg PO daily; tolterodine ER 4 mg PO daily
Paediatric: —

Add for OAB symptoms (urgency, frequency, nocturia) when residual urine acceptable; check PVR before adding (caution if >150 mL); dry mouth, constipation

Mirabegron (beta-3 agonist) for OAB component^[1]

Beta-3 agonist

Adult: 25–50 mg PO daily
Paediatric: —

Alternative to antimuscarinic; lower dry mouth burden; BP elevation; less anticholinergic side effects

Safety-net

Avoid sudden stopping of alpha-blocker before cataract surgery — it does not prevent floppy iris syndrome; tell your ophthalmologist about the medication^[1]
Inability to pass urine, severe lower abdominal pain or distension — same-day medical review for catheterisation^[1]
On 5-ARI: PSA halves over 6–12 months; if any rise from new nadir, investigate for prostate cancer^[1]

Referral criteria

Acute or chronic retention not relieved by trial without catheterUrology^[1]
Recurrent UTI, bladder stones, hydronephrosis, or persistent residual >300 mLUrology for surgical evaluation^[1]
Suspected prostate cancer (raised PSA, abnormal DRE, family history)Urology with multiparametric MRI prostate^[1]
Failure of medical therapy after 3–6 months at adequate doseUrology for surgical / MIST evaluation^[1]

Clinical summary

Diagnosis and stepwise medical and surgical management of male lower urinary tract symptoms attributed to BPH.

References

1.AUA Guideline on Surgical Management of LUTS Attributed to BPH (2018, with 2023–2024 updates including aquablation, Rezum, UroLift); EAU Non-Neurogenic Male LUTS (2024)