treatment of benign prostatic hyperplasia

Last edited 12/2018 and last reviewed 07/2021

Conservative management

• if a man has post micturition dribble then should be told how to perform urethral milking
  
  
• if storage LUTS (particularly urinary incontinence) then should be offered temporary containment products (for example, pads or collecting devices) to achieve social continence until a diagnosis and management plan have been discussed
  
  
• if storage LUTS suggestive of overactive bladder (OAB) then should be offered supervised bladder training, advice on fluid intake, lifestyle advice and, if needed, containment products
  
  
• supervised pelvic floor muscle training should be offered to men with stress urinary incontinence caused by prostatectomy
  • continue the exercises for at least 3 months before considering other options
    
    
• refer for specialist assessment men with stress urinary incontinence
  
  
• external collecting devices (for example, sheath appliances, pubic pressure urinals) should be offered for managing storage LUTS (particularly urinary incontinence) in men before considering indwelling catheterisation
  
  
• intermittent bladder catheterisation should be offered before indwelling urethral or suprapubic catheterisation to men with voiding LUTS that cannot be corrected by less invasive measures
  
  
• long-term indwelling urethral catheterisation should be considered for men with LUTS:
  • for whom medical management has failed and surgery is not appropriate and
  • who are unable to manage intermittent self-catheterisation or
  • with skin wounds, pressure ulcers or irritation that are being contaminated by urine or
  • who are distressed by bed and clothing changes
    
    
• consider permanent use of containment products for men with storage LUTS (particularly urinary incontinence) only after assessment and exclusion of other methods of management

Drug treatment

• offer drug treatment only to men with bothersome LUTS when conservative management options have been unsuccessful or are not appropriate
• offer an alpha blocker (alfuzosin, doxazosin, tamsulosin or terazosin) to men with moderate to severe LUTS, especially if voiding type (hesitancy, poor stream)
• offer a 5-alpha reductase inhibitor to men with LUTS who have prostates estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml, and who are considered to be at high risk of progression (for example, older men)
• consider offering a combination of an alpha blocker and a 5-alpha reductase inhibitor to men with bothersome moderate to severe LUTS and prostates estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml
• consider offering an anticholinergic as well as an alpha blocker to men who still have storage symptoms after treatment with an alpha blocker alone
• consider offering a late afternoon loop diuretic to men with nocturnal polyuria
• consider offering oral desmopressin to men with nocturnal polyuria if other medical causes have been excluded and they have not benefited from other treatments. Measure serum sodium 3 days after the first dose. If serum sodium is reduced to below the normal range, stop desmopressin treatment.

Reference:

• 1) NICE (June 2015). Lower urinary tract symptoms The management of lower urinary tract symptoms in men