Innovative approaches to benign prostatic hyperplasia management: Options beyond conventional treatment strategies

2.1 Pathophysiology and epidemiology

The non-cancerous widening of the prostate gland, which typically affects elderly men, is the hallmark of BPH. The prostate’s stromal and epithelial cell proliferation is a pathology of benign prostate hyperplasia (BPH), resulting in the formation of big, characteristic nodules in the vicinity of the urethra.²⁵ The symptoms of BPH are brought on by these nodules compressing the urethral canal, which can restrict the urethra partially or completely.²⁶ Hormonal changes that cause the prostate to grow, such as elevated levels of estrogen and DHT,^27,28 inflammation, and genetic predisposition all play important roles in the development of BPH.²⁹ Epidemiological studies reveal that BPH is a common condition in aging men to distress approximately 50% of those between the ages of 51 and 60 and up to 90% of those over 80.³⁰ Because of its increasing prevalence and severity with age, BPH is a serious health concern that greatly affects the quality of life and should be discerned from benign prostatic enlargement (BPE) and lacunculation (LUTS), the latter of which frequently necessitates medical consultation.³⁰ The IPSS (International Prostate Symptom Score) or the AUA (American Urological Association) symptom score is commonly used to measure the symptoms of LUTS, which include urge, frequency, nocturia, urgency, and dribbling after voiding. In older men, urodynamic changes such as benign prostatic hindrance and overactive or hypoactive detrusor muscles are the main causes of LUTS. The prevalence of BPH, BPE, and LUTS increases with age, with moderate to severe LUTS affecting roughly 20% of men in their 50s, 30% in their 60s, and 40% in their 80s.³¹ In Austria, it is estimated that approximately 350,000 men over 40 currently experience moderate to severe LUTS, a number expected to rise to around 500,000 in the next two decades due to demographic changes.^1,2 Despite its high prevalence and socioeconomic impact, the complete pathophysiology of BPH remains poorly understood, particularly why some men develop significantly larger prostates than others.³² Visibly, the mechanisms leading to LUTS are complex, involving various urodynamic patterns, changes in the bladder and urothelium, anticholinergic receptor status, and pelvic ischemia, highlighting the need for further research to develop effective treatments.^1,33

2.2 Symptoms and clinical presentation

Although BPH can manifest clinically in a variety of ways, lower urinary tract symptoms (LUTS) are generally linked to it.² LUTS are classified into three main categories by the International Continence Society (ICS): storage symptoms (affecting the bladder’s ability to store urine), voiding symptoms (difficulties in the bladder emptying process), and post-micturition symptoms (leakage after urination).³⁴

These symptoms shown in Table 1 can significantly impact a person’s quality of life, and addressing them with medical consultation is essential for proper management and relief.

2.3 Risk factors and demographic influences

Several risk factors have been identified for the development of BPH.³⁵ These risk factors are outlined in Figure 1.

Figure 1. Outline of the risk factors of BPH.

The main risk factor for BPH is age, as men age, and as a result, the frequency and intensity of symptoms both rise significantly.³⁶ Hormonal factors further exacerbate this, as androgens such as dihydrotestosterone (DHT) are critical for prostatic growth.²⁹ A further factor contributing to the illness may be an imbalance in the levels of estrogen and testosterone. Another factor is genetics; a family history of BPH raises the risk, suggesting a genetic predisposition; certain genetic markers have been shown to enhance the risk of developing BPH.³⁷ Furthermore, there is a considerable correlation between insulin resistance, obesity, hypertension, dyslipidemia, and other elements of metabolic syndrome and BPH, indicating the impact of general metabolic health on prostate enlargement.¹⁸ Moreover, lifestyle variables can have a major impact on the risk of BPH.³⁸ A higher incidence of BPH is associated with diets high in fat and red meat and low in fruits and vegetables; nevertheless, regular physical activity seems to offer a preventive effect. Studies reveal that African-American males are more prone than Caucasian men to acquire and have more severe types of BPH. Ethnicity also affects the prevalence and severity of BPH.³⁹ Comprehending the intricate relationships among these risk factors is crucial for healthcare practitioners to formulate efficacious management approaches customized to specific patient profiles, hence enhancing patient outcomes via individualized interventions.⁴⁰ In particular, healthcare professionals can better serve their patients’ needs by addressing the various pathophysiological causes, clinical manifestations, and demographic factors linked to BPH.²

3.1 Pharmacological treatments

As seen in Table 2, pharmacological treatments are frequently the initial line of treatment for BPH.⁴² These treatments can be broadly divided into two primary categories.

In pharmacological treatment, combination therapy with both α-blockers and 5-α-reductase inhibitors can be more effective than either treatment alone, especially in men with moderate to severe symptoms.¹¹

3.2 Surgical interventions

In the current treatment regimen for BPH, patients who do not respond to pharmacological treatments or have severe symptoms sorts for surgical interventions.⁴³ The most common surgical options are presented in Table 3.

3.3 Limitations of BPH standard treatment approaches

Despite the efficacy of conventional treatment options, several limitations exist ( Table 4). These limitations highlight the importance of exploring new and innovative treatment strategies beyond the norm for BPH that can offer better outcomes with fewer adverse effects.^11,42,43

4.1 Novel pharmacological agents

The goal of recent developments in BPH medication is to reduce adverse effects and increase efficacy. As shown in Table 5, several new agents are being studied or were just presented.^44,45

4.2 Minimally invasive surgical techniques

Minimally invasive techniques are becoming increasingly popular due to their effectiveness and reduced recovery times compared to traditional surgery.^46,47 These procedures aim to relieve obstruction while minimizing tissue damage (see Table 6).

4.3 Advances in BPH treatment technology

Technological advancements are continuously evolving the landscape of BPH treatment, providing less invasive, more effective options with faster recovery times and fewer complications^46,48 (see Table 7).

These emerging therapeutic strategies represent significant advancements in the management of BPH. By offering effective symptom relief with fewer side effects and faster recovery times, these innovations provide patients with more options to tailor their treatment to their specific needs and preferences.

5.1 Role of genetic and molecular profiling

Genetic and molecular profiling are revolutionizing the approach to managing BPH by providing deeper insights into the disease’s underlying mechanisms and individual patient variability. In terms of genetic profiling, researchers have identified several genetic markers associated with an increased risk of BPH. For instance, variations in genes interrelated to androgen metabolism, inflammation, and growth factor signaling have been allied to the development and progression of BPH.²⁵ Similarly, understanding genetic differences in drug metabolism and response can help predict which patients are prospective to benefit from specific medications. For case, dissimilarities in genes encoding enzymes fingered in drug metabolism can distress the efficacy and safety of α-blockers and 5-α-reductase inhibitors.⁴² Additionally, molecular profiling can identify biomarkers that predict disease progression and response to treatment. For instance, levels of prostate-specific antigen (PSA) and other novel biomarkers can provide information about the severity of BPH and the likelihood of progression.⁴⁹ Furthermore, analysis of molecular pathways involved in BPH, such as those regulating cell proliferation, apoptosis, and inflammation, can identify potential therapeutic targets and guide the development of targeted therapies.^50,51

5.2 Customized treatment plans based on patient characteristics

Personalized medicine encompasses tailoring treatment tactics to the individual characteristics of each patient, enhancing the effectiveness and minimizing adverse effects.^47,52

5.2.1 Patient characteristics

Imaging studies such as ultrasound and MRI can provide detailed information about prostate size, shape, and the presence of specific anatomical features (e.g., median lobe enlargement) that may influence treatment choices.⁵³ Also, the IPSS and quality of life assessments help gauge the severity of symptoms and their impact on daily activities, guiding the intensity and type of treatment.³⁰ Overall, a comprehensive evaluation of the patient’s overall health, including the presence of comorbid conditions (e.g., cardiovascular disease, diabetes) and current medications, ensures that treatment plans are safe and effective.^52,54

5.2.2 Tailored therapies

Based on genetic and molecular profiling, healthcare providers can choose the most suitable medications and adjust dosages to optimize efficacy and reduce side effects.²⁵ For instance, patients with genetic variations affecting drug metabolism may require alternative dosing strategies. Similarly, customized surgical plans take into account the patient’s prostate anatomy and inclusive health.⁵³ For example, minimally invasive techniques like the UroLift or Rezum might be preferred for patients with certain anatomical profiles or those who are at higher risk for surgical complications.⁴⁷

6.1 Lifestyle modifications and their impact on BPH

Lifestyle modifications play a decisive role in the holistic management of BPH by potentially reducing symptoms and slowing disease progression⁵⁵ (see Table 8).

6.2 Diet and nutrition recommendations

Diet and nutrition are critical components of holistic BPH management, with certain dietary patterns and nutrients associated with reduced risk and symptom relief^56,57 (see Table 9).

6.3 Complementary and alternative therapies

Complementary and alternative therapies can offer additional relief for BPH symptoms and improve overall well-being⁵⁸ (see Table 10).

Integrating these holistic and alternative approaches with conventional medical treatments can provide a comprehensive management strategy for BPH, addressing not only the physical symptoms but also enhancing overall health and quality of life.

7.1 Managing associated conditions

7.1.1 Bladder dysfunction

Proper assessment of bladder dysfunction in BPH patients is critical. Urodynamic studies can diagnose the type and extent of bladder issues, such as detrusor overactivity or impaired contractility. Management involves behavioral therapies like bladder training and pelvic floor muscle exercises, which can improve bladder control. Medications, including antimuscarinics or beta-3 agonists, may be prescribed to manage overactive bladder symptoms, reducing urgency, frequency, and incontinence episodes. For severe bladder dysfunction, surgical interventions such as bladder neck incision or augmentation cystoplasty might be necessary.^59,60

7.1.2 Urinary tract infections (UTIs)

According to Fisher et al.,⁶⁰ preventing UTIs involves maintaining good hydration and proper hygiene. In recurrent cases, prophylactic antibiotics may be used as treatment requires appropriate antibiotic therapy based on culture and sensitivity results, with long-term low-dose antibiotics considered for recurrent UTIs.⁶¹ Also, if chronic prostatitis is suspected, longer courses of antibiotics targeting prostate tissue may be necessary.⁶²

7.2.3 Chronic kidney disease (CKD)

Regular nursing of renal function through blood tests (e.g., estimated glomerular filtration rate and serum creatinine) and urine analysis is essential.⁶³ Managing CKD involves addressing the underlying cause of urinary obstruction and ensuring proper urinary drainage to prevent further kidney damage. Referral to a nephrologist for comprehensive management of CKD and associated conditions may be required.⁶⁴

7.2 Strategies for dealing with treatment-resistant BPH

7.2.1 Reassessment and diagnosis

For treatment-resistant BPH, a detailed evaluation of the patient’s symptoms, imaging studies (e.g., transrectal ultrasound, MRI), and urodynamic testing can help understand the resistance to treatment. Identifying contributing factors, such as bladder stones, strictures, or neurogenic bladder, is essential for targeted management.⁵³

7.2.2 Advanced pharmacotherapy

Combination therapy with α-blockers and 5-α-reductase inhibitors may maximize symptom relief. Therefore, exploring alternative medications, such as PDE5 inhibitors (e.g., tadalafil), or off-label uses like botulinum toxin injections into the prostate or bladder, can also be considered.⁶⁵

7.2.3 Minimally invasive procedures

Prostatic Artery Embolization (PAE) is a non-surgical option that reduces prostate volume by decreasing its blood supply. Consequently, Convective Water Vapor Therapy (Rezum) uses thermal energy to ablate excess prostate tissue, effective in treatment-resistant cases.⁶⁶

7.2.4 Surgical interventions

Holmium Laser Enucleation of the Prostate (HoLEP) is effective for larger prostates and provides long-term symptom relief. Hence, Open or robot-assisted simple prostatectomy is considered for very large prostates where minimally invasive techniques may not be effective.⁶⁷

7.3 Post-treatment follow-up and monitoring

7.3.1 Regular follow-up visits

Initially, frequent visits (e.g., every 3-6 months) post-treatment are necessary to monitor recovery and response, gradually reducing to annual check-ups if stable. Therefore, a comprehensive evaluation using the IPSS, physical examination, and PSA testing if indicated is essential.³⁴

7.3.2 Monitoring for complications

Immediately post-treatment, monitoring for signs of bleeding, infection, and urinary retention is critical, ensuring proper catheter care if used. So, long-term hitches, such as bladder neck contractures, urethral strictures, or recurrent BPH, should also be watched for.⁶⁸

7.3.3 Lifestyle and health maintenance

Encouraging healthy habits like weight management, regular physical activity, and a balanced diet is vital. Hence, patient education on recognizing symptoms of complications or recurrence and advising on when to seek medical attention is also important.

7.3.4 Adjunct therapies and support

Referral to a physical therapist for pelvic floor exercises can improve urinary control and reduce symptoms. Hence, addressing the psychological impact of BPH and its treatment through counseling or support groups is also beneficial.

7.3.4 Coordinated care

A multidisciplinary approach involving urologists, primary care physicians, physical therapists, and other specialists as needed ensures comprehensive care. Therefore, effective patient-centered communication keeps patients well-informed about their condition, treatment options, and the importance of adherence to follow-up schedules.

Generally, addressing complications and comorbidities in BPH requires a multifaceted approach combining careful monitoring, advanced treatment strategies, and holistic patient care. These elements, if properly integrated can help healthcare providers enhance patient outcomes and quality of life.