Risk stratification for benign prostatic hyperplasia (BPH) treatment

What’s known on the subject? and What does the study add? Patients with BPH have traditionally been managed with ‘sequential monotherapy’ or effectively an intent to treat to failure. Thus watchful waiting strategies, α‐blockers, 5α‐reductase inhibitors and surgical intervention have been seen as a stepwise progression based on failure of symptom control at each level. This paper reviews the evidence from large randomized trials which suggest a new approach of risk stratification, allowing the identification of higher risk patients for whom medical management can be optimised at an early stage. If this can be done at a primary care level, this could lead to a dramatic improvement in outcomes in men with BPH. • Benign prostatic hyperplasia (BPH) is a common cause of bothersome lower urinary tract symptoms. In the past, the aim of drug treatment was to relieve symptoms until surgery became necessary, predominantly using an α‐blocker or a 5α‐reductase inhibitor (5ARI) as monotherapy. • Together with improving knowledge about the pathogenesis of BPH, there is now strong evidence from large randomized trials that risk stratification and appropriate treatment with combined α‐blocker/5ARI therapy can significantly reduce the risk of disease progression and avoid long‐term complications such as acute urinary retention and surgery. • BPH will increasingly be managed in primary care in the future and, if new management strategies based on this evidence are to be implemented cost effectively, there is a need to introduce shared care between the primary and secondary care sectors to optimise use of resources and expertise.