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Benign prostatic hyperplasia (BPH) is the most common cause of lower urinary tract symptoms in men. This article provides a review of the available patient-oriented evidence to evaluate and manage lower urinary tract symptoms from BPH. Use of the term “men” in this article is intended to include those who have male sex assigned at birth.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Grade lower urinary tract symptoms using the IPSS. 5,10 C Systematic review showing that the IPSS is the only grading score to predict bladder outlet obstruction; use is recommended by the American Urological Association
Recommend self-management methods, including limited evening fluid intake, reducing caffeine and alcohol intake, toilet and bladder training, sitting to urinate, urethral milking, double voiding, bladder retraining, pelvic floor exercises, and mindfulness techniques to improve symptoms. 5,14–17 B Randomized controlled trials and meta-analyses showing benefit in reducing lower urinary tract symptoms
Begin medical treatment with alpha blocker or phosphodiesterase-5 inhibitors, which have similar effects; no benefit occurs in combining these medications. 8,18,25 A Systematic reviews demonstrate similar effectiveness and no benefit with combination therapy
5-Alpha reductase inhibitors improve lower urinary tract symptoms and reduce urinary retention but can take a year to reach their full effect; benefit may occur with combination treatment with alpha blockers. 20,21 A Systematic review and meta-analysis demonstrate improvement in symptoms and slower progression
Transurethral resection of the prostate is the most effective surgical procedure, although other procedures have lower risks of bleeding, incontinence, and sexual adverse effects. 34 A Systematic review

IPSS = International Prostate Symptom Score.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

BEST PRACTICES IN UROLOGY

Recommendations From Choosing Wisely

Recommendation Sponsoring organization
Do not order creatinine or upper tract imaging for patients with benign prostatic hyperplasia. American Urological Association

Source: For more information on Choosing Wisely, see https://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://www.aafp.org/pubs/afp/collections/choosing-wisely.html.

Epidemiology

  1. Lower urinary tract symptoms from BPH affect 38.1 million men older than 30 years in the United States, about one-fourth of all U.S. men. 1

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