Guideline sources The following summarized guidelines for the evaluation and management of benign prostatic hyperplasia (BPH) are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2022), the Canadian Urological Association (CUA 2022), and the American Urological Association (AUA 2021). 1 3 4 5 Calculator International Prostate Symptom Guidelines 1. Diagnostic investigations https://web.pathway.md/diseases/reclJV1leKHUqIf9D 1/11 6/29/23, 3:17 AM Benign prostatic hyperplasia Pathway History and physical examination: As per EAU 2022 guidelines, elicit a complete medical history in patients with LUTS. A Show 3 more As per AUA 2021 guidelines, elicit a medical history, perform a physical examination, and utilize the AUA-SI and IPSS in the initial evaluation of patients presenting with bothersome LUTS possibly attributed to BPH. B Urinalysis: As per EAU 2022 guidelines, obtain urinalysis (by dipstick or urinary sediment) in the assessment of patients with LUTS. A As per AUA 2021 guidelines, obtain urinalysis in the initial evaluation of patients presenting with bothersome LUTS possibly attributed to BPH. B Renal function tests: assess renal function if renal impairment is suspected based on history and clinical examination, or in the presence of hydronephrosis, or when considering surgical treatment for LUTS. A Prostate-specific antigen: Measure PSA if a diagnosis of prostate cancer will change management. A Measure PSA if it assists in the treatment and/or decision-making process. A Diagnostic imaging: As per EAU 2022 guidelines, obtain ultrasound of the upper urinary tract in patients with LUTS. B Show 3 more As per AUA 2021 guidelines, consider assessing the prostate size and shape via transrectal or abdominal ultrasound, cystoscopy, or cross-sectional imaging (MRI/CT), if available, before interventions for LUTS secondary/attributed to BPH. C Show 3 more Urodynamic testing: As per EAU 2022 guidelines, obtain uroflowmetry in the initial assessment of patients with LUTS. B Show 7 more As per AUA 2021 guidelines: Consider obtaining uroflowmetry before interventions for LUTS secondary/attributed to BPH. C Consider obtaining pressure flow studies before interventions for LUTS secondary/attributed to BPH, if diagnostic uncertainty exists. E 2. Diagnostic procedures Urethrocystoscopy: https://web.pathway.md/diseases/reclJV1leKHUqIf9D 2/11 6/29/23, 3:17 AM Benign prostatic hyperplasia Pathway As per EAU 2022 guidelines, perform urethrocystoscopy in patients with LUTS before minimally invasive/surgical therapies if the findings may change treatment. B As per AUA 2021 guidelines, consider assessing the prostate size and shape via cystoscopy, if available, before interventions for LUTS secondary/attributed to BPH. C 3. Medical management Watchful waiting: offer watchful waiting in patients with mild/moderate symptoms, minimally bothered by their symptoms. A Alpha-blockers: As per CUA 2022 guidelines: Offer alpha-blockers as an excellent first-line therapeutic option in patients with symptomatic BPH. A Consider offering alpha-blocker therapy during the period of catheterization in patients with acute urinary retention secondary to BPH. C As per EAU 2022 guidelines, offer alpha-1 blockers in patients with moderate-to-severe LUTS. A As per AUA 2021 guidelines, offer any of the following alpha-blockers (choice of agent based on patient age and comorbidities, and different adverse event profiles such as ejaculatory dysfunction, changes in BP) as a treatment option in patients with bothersome, moderate-to- severe LUTS secondary/attributed to BPH: alfuzosin doxazosin silodosin tamsulosin terazosin. B Show 4 more 5-alpha reductase inhibitors: As per CUA 2022 guidelines, offer 5-ARIs (dutasteride and finasteride) as an appropriate and effective treatment in patients with LUTS associated with demonstrable prostatic enlargement. A Show 2 more As per EAU 2022 guidelines, offer 5-ARIs in patients with moderate-to-severe LUTS and an increased risk of disease progression (such as prostate volume > 40 mL). Counsel patients about the slow onset of action of 5-ARIs. A As per AUA 2021 guidelines, offer 5-ARI monotherapy as an option for improvement of symptoms in patients with LUTS secondary/attributed to BPH with prostatic enlargement as judged by any of the following: prostate volume of > 30 ml on imaging https://web.pathway.md/diseases/reclJV1leKHUqIf9D 3/11 6/29/23, 3:17 AM Benign prostatic hyperplasia Pathway PSA > 1.5 ng/dL palpable prostate enlargement on digital rectal exam. B Show 3 more As per AUA 2021 guidelines, consider initiating 5-ARIs in patients with refractory hematuria presumably due to prostatic bleeding, after exclusion of other causes of hematuria. E Phosphodiesterase-5 inhibitors: As per CUA 2022 guidelines, offer long-acting PDE5 inhibitors as monotherapy in patients with LUTS/BPH, particularly in patients with both LUTS and erectile dysfunction. B As per EAU 2022 guidelines, offer PDE5 inhibitors in patients with moderate-to-severe LUTS, with or without erectile dysfunction. A As per AUA 2021 guidelines, consider offering tadalafil 5 mg daily as a treatment option in patients with LUTS secondary/attributed to BPH, irrespective of comorbid erectile dysfunction. C Anticholinergic agents: As per CUA 2022 guidelines, consider offering antimuscarinic agents in patients with BPH with predominately storage symptoms. Be cautious when using in patients with significant bladder outlet obstruction and/or an elevated post-void residual volume. C As per EAU 2022 guidelines: Offer antimuscarinic agents in patients with moderate-to-severe LUTS with predominately bladder storage symptoms. A Do not use antimuscarinic overactive bladder medications in patients with a post-void residual volume > 150 mL. D As per AUA 2021 guidelines, consider offering anticholinergic agents, alone or in combination with an alpha-blocker, as a treatment option in patients with moderate-to-severe predominant storage LUTS. C Beta-3 agonists: As per CUA 2022 guidelines, consider offering -3 agonists in patients with BPH with predominately storage symptoms. Be cautious when using in patients with significant bladder outlet obstruction and/or an elevated post-void residual volume. C As per EAU 2022 guidelines, offer -3 agonists in patients with moderate-to-severe LUTS with predominately bladder storage symptoms. B Combination therapy: As per CUA 2022 guidelines, offer combination therapy with an alpha-blocker and a 5-ARI in patients with LUTS associated with prostatic enlargement (> 30 mL). B Show 2 more As per EAU 2022 guidelines, offer combination treatment with an alpha-1 blocker and a 5-ARI in patients with moderate-to-severe LUTS and an increased risk of disease progression (such as prostate volume > 40 mL). A Show 3 more https://web.pathway.md/diseases/reclJV1leKHUqIf9D 4/11 6/29/23, 3:17 AM Benign prostatic hyperplasia Pathway As per AUA 2021 guidelines, consider offering a 5-ARI in combination with an alpha-blocker as a treatment option only in patients with LUTS associated with demonstrable prostatic enlargement as judged by any of the following: prostate volume of > 30 mL on imaging PSA > 1.5 ng/dL palpable prostate enlargement on digital rectal exam. B Show 3 more Management of nocturia (addressing underlying causes): treat underlying causes of nocturia, including behavioral, systemic conditions, sleep disorders, lower urinary tract dysfunction, or a combination of factors. B Management of nocturia (behavioral changes): discuss behavioral changes with the patient to reduce nocturnal urine volume and episodes of nocturia and improve sleep quality. B Management of nocturia, desmopressin: As per CUA 2022 guidelines, offer desmopressin as a therapeutic option in patients with LUTS/BPH with nocturia as a result of nocturnal polyuria. B As per EAU 2022 guidelines, offer desmopressin to decrease nocturia due to nocturnal polyuria in < 65 years old patients. B Show 3 more Management of nocturia (anti-LUTS therapy): offer alpha-1 blockers for the treatment of nocturia in patients with nocturia associated with LUTS. B Show 3 more Management of urinary incontinence (evaluation): elicit a complete medical history including symptoms and comorbidities, medications, and perform a focused physical examination in the evaluation of patients with urinary incontinence. A Show 3 more Management of urinary incontinence (conservative management): offer lifestyle advice to improve urinary incontinence. Inform patients that the evidence for these interventions is lacking. B Show 5 more Management of urinary incontinence (pharmacotherapy): Offer antimuscarinic agents or mirabegron in patients with urge urinary incontinence failed conservative treatment. A Offer duloxetine in patients with stress urinary incontinence. B Inform patients about the possible adverse events of duloxetine. A Management of urinary incontinence (surgical management): do not offer bulking agents in patients with postprostatectomy incontinence. D Show 7 more Management of urinary incontinence (other therapeutic interventions): offer bladder wall injections of onabotulinum toxin A 100 U in patients with overactive bladder/urgency urinary https://web.pathway.md/diseases/reclJV1leKHUqIf9D 5/11 6/29/23, 3:17 AM Benign prostatic hyperplasia Pathway incontinence refractory to medical therapy. B Show 2 more 4. Nonpharmacologic interventions Phytotherapy: As per CUA 2022 guidelines, do not offer phytotherapies as standard treatment in patients with LUTS/BPH. D As per EAU 2022 guidelines, offer hexanic extract of Serenoa repens in patients with LUTS wishing to avoid any potential adverse events especially related to sexual function. B Inform patients that the magnitude of the efficacy of hexanic extract of Serenoa repens may be modest. A 5. Therapeutic procedures Prostatic artery embolization: As per CUA 2022 guidelines, consider offering prostatic artery embolization at centers with urological and radiological collaboration and technical expertise in highly selected, well-informed patients wishing to consider an alternative treatment option. Inform patients about the lack of long-term durability. C As per EAU 2022 guidelines: Offer prostatic artery embolization in patients with moderate-to-severe LUTS wishing to consider minimally invasive treatment options and accept less optimal outcomes compared with TURP. B Perform prostatic artery embolization only in units where the work-up and follow-up are obtained by urologists working collaboratively with trained interventional radiologists for the identification of prostatic artery embolization suitable patients. A As per AUA 2021 guidelines, do not perform prostatic artery embolization for the treatment of patients with LUTS secondary/attributed to BPH outside the context of clinical trials. D Prostatic stenting: consider offering prostatic stenting only as an alternative to catheterization in patients unfit for surgery with a functional detrusor. C Temporary implantable nitinol device: offer implantation of a temporary implantable nitinol device in patients with LUTS interested in preserving ejaculatory function with prostate volume of 30-80 mL. Inform patients about the higher retreatment rate at 3 years. B Intraprostatic botulinum toxin injection: do not offer intraprostatic botulinum toxin-A injection for the treatment of patients with LUTS. D 6. Surgical interventions Indications for surgery: https://web.pathway.md/diseases/reclJV1leKHUqIf9D 6/11 6/29/23, 3:17 AM Benign prostatic hyperplasia Pathway Perform surgery in patients with any of the following: renal insufficiency secondary to BPH refractory urinary retention secondary to BPH recurrent UTIs recurrent bladder stones or gross hematuria due to BPH LUTS secondary/attributed to BPH refractory to or unwilling to use other therapies. B Do not perform surgery solely for the presence of an asymptomatic bladder diverticulum. Consider evaluating for the presence of bladder outlet obstruction in these cases. D Transurethral resection: As per CUA 2022 guidelines, offer monopolar A or bipolar TURP as a standard first-line surgical therapy in patients with moderate-to-severe LUTS/BPH with a prostate volume of 30-80 mL. B As per EAU 2022 guidelines, offer bipolar or monopolar TURP in patients with moderate-to- severe LUTS with a prostate volume of 30-80 mL. A As per AUA 2021 guidelines: Offer TURP as a treatment option in patients with LUTS secondary/attributed to BPH. B Consider using either monopolar or bipolar approach to TURP depending on the clinician's expertise with these techniques. E Transurethral incision: As per CUA 2022 guidelines, offer transurethral incision of the prostate for the treatment of moderate-to-severe LUTS in patients with prostate volume < 30 mL without a middle lobe. Inform patients about the high retreatment rate. B As per EAU 2022 guidelines, offer transurethral incision of the prostate in patients with moderate-to-severe LUTS with prostate volume < 30 mL, without a middle lobe. A As per AUA 2021 guidelines, offer transurethral incision as a treatment option in patients with LUTS secondary/attributed to BPH provided prostate volume is 30 mL. B Transurethral vaporization: As per EAU 2022 guidelines, offer bipolar transurethral vaporization of the prostate as an alternative to TURP in patients with moderate-to-severe LUTS with a prostate volume of 30-80 mL. B As per AUA 2021 guidelines, consider offering bipolar transurethral vaporization of the prostate as a treatment option in patients with LUTS secondary/attributed to BPH. C Transurethral microwave therapy: As per CUA 2022 guidelines, consider offering transurethral microwave therapy as an option in carefully selected, well-informed patients with LUTS/BPH. C As per AUA 2021 guidelines, consider offering transurethral microwave therapy as a treatment option in patients with LUTS secondary/attributed to BPH. C https://web.pathway.md/diseases/reclJV1leKHUqIf9D 7/11 6/29/23, 3:17 AM Benign prostatic hyperplasia Pathway Transurethral needle ablation: do not perform transurethral needle aspiration for the treatment of patients with LUTS secondary/attributed to BPH. D Anatomical endoscopic enucleation: offer anatomic endoscopic enucleation of the prostate (performed by a trained surgeon) as an alternative to TURP or open simple prostatectomy in patients with moderate-to-severe LUTS and any size prostate > 30 mL. Recognize that anatomic endoscopic enucleation of the prostate can be safely performed in patients on anticoagulant/antiplatelet therapy. A Laser enucleation: As per EAU 2022 guidelines, offer laser resection of the prostate using Tm:YAG laser as an alternative to TURP. B Show 4 more As per AUA 2021 guidelines: Consider performing holmium or thulium laser enucleation of the prostate as a treatment option in patients at higher risk of bleeding. E Decide on performing holmium or thulium laser enucleation of the prostate as prostate size- independent treatment options based on the clinician's expertise with these techniques. B Plasmakinetic enucleation: offer bipolar transurethral (plasmakinetic) enucleation of the prostate as an alternative to TURP in patients with moderate-to-severe LUTS. B Photoselective vaporization: As per CUA 2022 guidelines: Offer photoselective vaporization of the prostate as an alternative to monopolar or bipolar TURP in patients with moderate-to-severe LUTS. A Consider offering GreenLight photoselective vaporization therapy as an alternative surgical approach in patients on anticoagulation or with a high cardiovascular risk. C As per EAU 2022 guidelines, offer 80W 532 nm potassium-titanyl-phosphate laser vaporization of the prostate as an alternative to TURP in patients with moderate-to-severe LUTS with a prostate volume of 30-80 mL. A Show 3 more As per AUA 2021 guidelines: Consider offering photoselective vaporization of the prostate as a treatment option in patients at higher risk of bleeding. E Offer photoselective vaporization of the prostate using 120W or 180W platforms as a treatment option in patients with LUTS secondary/attributed to BPH. B Prostatic urethral lift: As per CUA 2022 guidelines: Consider offering prostatic urethral lift as an alternative treatment in patients with LUTS interested in preserving ejaculatory function with prostate volume < 80 mL. C Consider offering prostatic urethral lift in patients with a small-to-moderate median lobe and bothersome LUTS. Inform patients (with or without a median lobe) about the higher https://web.pathway.md/diseases/reclJV1leKHUqIf9D 8/11 6/29/23, 3:17 AM Benign prostatic hyperplasia Pathway retreatment rate at 5 years. C As per EAU 2022 guidelines, offer prostatic urethral lift in patients with LUTS interested in preserving ejaculatory function, with prostate volume < 70 mL and no middle lobe. A As per AUA 2021 guidelines: Consider offering prostatic urethral lift as a treatment option in patients with LUTS secondary/attributed to BPH provided prostate volume 30-80 mL and verified absence of an obstructive middle lobe. C Consider offering prostatic urethral lift as a treatment option in eligible patients desiring preservation of erectile and ejaculatory function. C Water vapor thermal therapy: As per CUA 2022 guidelines, consider offering the Rez m system of convective water vapor energy ablation as an alternative treatment in patients with LUTS interested in preserving ejaculatory function with prostate volume < 80 mL, including patients with a median lobe. C As per AUA 2021 guidelines: Consider offering water vapor thermal therapy as a treatment option in patients with LUTS secondary/attributed to BPH provided prostate volume 30-80 mL. C Consider offering water vapor thermal therapy as a treatment option in eligible patients desiring preservation of erectile and ejaculatory function. C Robotic waterjet ablation: As per CUA 2022 guidelines, consider offering aquablation in patients with LUTS interested in preserving ejaculatory function with prostate volume < 150 mL, with or without a middle lobe. C As per EAU 2022 guidelines, offer aquablation as an alternative to TURP in patients with moderate-to-severe LUTS and a prostate volume of 30-80 mL. B Inform patients about the risk of bleeding and the lack of long-term follow-up data. A As per AUA 2021 guidelines, consider offering robotic waterjet ablation as a treatment option in patients with LUTS secondary/attributed to BPH provided prostate volume 30-80 mL. C Simple prostatectomy: As per CUA 2022 guidelines: Offer open simple prostatectomy as first-line surgical therapy in patients with moderate-to- severe LUTS/BPH and enlarged prostate volume > 80 mL, if anatomic endoscopic enucleation of the prostate is unavailable. A Offer laparoscopic simple prostatectomy or robot-assisted simple prostatectomy as alternative surgical therapies in patients with moderate-to-severe LUTS/BPH and enlarged prostate volume > 80 mL in centers where there are surgeons with high-level expertise in laparoscopy or robotics. B As per EAU 2022 guidelines, offer open prostatectomy in the absence of bipolar transurethral enucleation of the prostate and holmium laser enucleation of the prostate in patients with moderate-to-severe LUTS with prostate volume > 80 mL. A https://web.pathway.md/diseases/reclJV1leKHUqIf9D 9/11 6/29/23, 3:17 AM Benign prostatic hyperplasia Pathway As per AUA 2021 guidelines, consider offering open, laparoscopic, or robot-assisted prostatectomy, depending on the clinician's expertise with these techniques, as treatment options only in patients with large-to-very large prostates. C 7. Patient education General counseling: As per EAU 2022 guidelines, offer lifestyle advice and self-care information before or concurrent with treatment in patients with LUTS. A As per AUA 2021 guidelines, inform patients of the possibility of treatment failure and the need for additional or secondary treatments when considering surgical and minimally-invasive treatments for LUTS secondary to BPH. B As per AUA 2021 guidelines, counsel patients regarding the options for intervention including behavioral/lifestyle modifications, medical therapy and/or referral for discussion of procedural options. E 8. Follow-up and surveillance Follow-up: As per EAU 2022 guidelines: Follow-up all patients receiving conservative, medical, or surgical management. B Define follow-up intervals and examinations according to the specific treatment. B As per AUA 2021 guidelines: Evaluate patients 4-12 weeks after initiating treatment (provided adverse events do not require earlier consultation) to assess response to therapy. Obtain IPSS during reevaluation. Consider obtaining a post-void residual and uroflowmetry during further evaluation. B Obtain further evaluation and consider changing medical management or surgical intervention in patients with bothersome LUTS secondary/attributed to BPH elected initial medical management and not having symptom improvement and/or experiencing intolerable side effects. E Clinical findings Patient demographics Symptoms Male sex Feeling of incomplete bladder emptying Past medical history Nocturia Split urine stream Diabetes mellitus type 2 Terminal dribbling Obesity Urinary frequency https://web.pathway.md/diseases/reclJV1leKHUqIf9D 10/11 6/29/23, 3:17 AM Benign prostatic hyperplasia Pathway Urinary hesitancy Rectal exam Urinary incontinence Enlarged prostate Urinary straining Urinary urgency Weak urine stream Vital signs Hypertension References 1. S. Gravas, J.N. Cornu, M. Gacci et al. EAU Guidelines on Management of Non-Neurogenic Male Lower Urinary Tract Symptoms LUTS , incl. Benign Prostatic Obstruction BPO . EAU. 2022 Mar. Open 2. J Kellogg Parsons, Philipp Dahm, Tobias S K hler et al. Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline Amendment 2020. J Urol. 2020 Oct;204 4 799 804. Open 3. Lori B Lerner, Kevin T McVary, Michael J Barry et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART II Surgical Evaluation and Treatment. J Urol. 2021 Oct;206 4 818 826. Open 4. Dean Elterman, M lanie Aub -Peterkin, Howard Evans et al. UPDATE Canadian Urological Association guideline: Male lower urinary tract symptoms/benign prostatic hyperplasia. Can Urol Assoc J. 2022 Aug;16 8 245 256. Open 5. Lori B Lerner, Kevin T McVary, Michael J Barry et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART I Initial Work-up and Medical Management. J Urol. 2021 Oct;206 4 806 817. Open 6. American Urological Association. Choosing Wisely AUA recommendations. Choosing Wisely. 2017. Open 7. Foster HE, Barry MJ, Dahm P et al. Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline. J Urol. 2018 Sep;200 3 612 619. Open 8. M J Barry, F J Fowler Jr, M P O'Leary et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol. 1992 Nov;148 5 1549 57; discussion 1564. Open https://web.pathway.md/diseases/reclJV1leKHUqIf9D 11/11