Lower urinary tract symptoms are experienced by patients with BPH and are most valued by the patients themselves. Lower urinary tract symptoms and the resulting decrease in quality of life are the main reasons for patients to seek treatment, depending on their tolerance level. Therefore, the degree of lower urinary tract symptoms and quality of life decline is an important basis for the selection of treatment measures. The patient’s wishes should be fully understood, and the efficacy and side effects of various treatments, including watchful waiting, medication, and surgical treatment, should be explained to the patient. Watchful waiting is a non-pharmacologic, non-surgical treatment measure that includes patient education, lifestyle guidance, and follow-up. Because BPH is a progressive benign hyperplasia process in prostate histology, its development is difficult to predict, and after a long period of follow-up, only a minority of BPH patients may develop complications such as urinary retention, renal insufficiency renal insufficiency, bladder stones, and so on [1-2]. Therefore, watchful waiting can be an appropriate management for most patients with BPH, especially when the patient’s quality of life has not been significantly affected by lower urinary tract symptoms. 1, Recommendations Watchful waiting can be used for patients with mild lower urinary tract symptoms (I-PSS score ≤7) and for patients with more than moderate symptoms (I-PSS score ≥8) while their quality of life has not yet been significantly affected. Prior to watchful waiting, patients should undergo a comprehensive examination (all components of the initial assessment) to exclude various BPH-related comorbidities. Clinical outcomes 85% of patients on watchful waiting remained stable at 1 year of follow-up and 65% had no clinical progression at 5 years [3]. In one study, 556 BPH patients with moderate lower urinary tract symptoms were divided into two groups: surgical treatment and watchful waiting. 36% of the patients in the watchful waiting group were transferred to the surgical treatment group at 5 years of follow-up, and 64% remained stable [4]. (1) Patient education: Patients undergoing watchful waiting should be provided with knowledge about BPH, including lower urinary tract symptoms and clinical progress of BPH, and in particular should be made aware of the effects and prognosis of watchful waiting. Knowledge about prostate cancer should also be provided; patients with BPH are often more concerned about the risk of prostate cancer, and studies have shown that the detection rate of prostate cancer in people with lower urinary tract symptoms is no different from that of their asymptomatic peers [5]. (2) Lifestyle guidance: Appropriate restriction of water intake can alleviate urinary frequency symptoms, such as limiting water intake at night and when attending public social occasions. However, daily water intake should not be less than 1500 ml. Alcohol and coffee have diuretic and stimulant effects, which can cause symptoms such as increased urinary output, urinary frequency, and urinary urgency. Therefore, the intake of alcoholic and caffeinated beverages should be appropriately limited. Instruction on bladder emptying techniques, such as repeated urination. Mental relaxation training to divert attention from the desire to urinate. Bladder training to encourage the patient to hold urine appropriately to increase bladder capacity and intervals between voiding. Guidance on co-medication: Patients with BPH often use multiple medications in combination with other systemic diseases, and should be informed of and evaluated for these co-medications, and adjustments should be made, if necessary, under the guidance of other specialists to minimize the impact of co-medication on the urinary system. Treatment of coexisting constipation. 4, Follow-up Follow-up is an important clinical process for patients undergoing observation waiting for BPH. The first follow-up is conducted in the 6th month after the start of observation waiting, and then once a year thereafter. The purpose of the follow-up visit is to understand the patient’s condition, whether there is clinical progression and BPH-related comorbidities and/or absolute surgical indications, and to switch to pharmacological or surgical treatment according to the patient’s wishes. Follow-up visits consisted of the elements of the initial evaluation. Second, drug therapy The short-term goal of drug therapy for patients with BPH is to relieve the patient’s lower urinary tract symptoms, and the long-term goal is to slow the clinical progression of the disease and prevent the development of comorbidities. Reducing the side effects of drug therapy while maintaining a high quality of life for patients is the overall goal of drug therapy for BPH. 1, α-blocker (1) α-blocker mechanism of action and urinary tract selectivity: α-blocker is through the blockade of adrenergic receptors distributed on the surface of the smooth muscle of the prostate and bladder neck, relaxation of smooth muscle, to achieve relief of bladder outlet power obstruction. Alpha-blockers can be categorized according to uroselectivity into nonselective alpha-blockers (phenoxybenzamine, Phenoxybenzamine), selective alpha1-blockers (Doxazosin, Alfuzosin, Terazosin) and highly selective alpha1-blockers (Tamsulosin Tamsulosin-α1A>α1D, Naftopidil Naftopidil-α1D>α1A). (2) Recommendation: alpha-blockers are indicated for BPH patients with lower urinary tract symptoms. Tamsulosin, doxazosin, alfuzosin, and terazosin are recommended for the pharmacologic treatment of BPH. Naftopidil and other applications can be chosen for the treatment of BPH. (3) Clinical efficacy: The clinical use of alpha-blockers for the treatment of BPH-induced lower urinary tract symptoms began in the 1970s [6]. Meta-analysis by Djavan and Marberger showed that, compared with placebo, various alpha1-blockers significantly improved the symptoms of the patients, resulting in an average improvement in symptom scores of 30%-40% and an increase in the maximum urinary flow rate of 16%-25% [7]. 25% [7]. Phenobarbamol, which was initially used, had significant side effects, making it difficult to be accepted by patients. Symptomatic improvement can be seen as early as 48 hours after α-blocker therapy, but assessment of symptomatic improvement using the I-PSS should be done after 4 to 6 weeks of medication. Continuous use of alpha-blockers for 1 month without significant symptom improvement should not be continued [8]. The results of a clinical study on tamsulosin treatment of BPH for up to 6 years showed that long-term use of alpha-blockers maintains stable efficacy [9]. Also the MTOPS study confirmed the long-term efficacy of alpha-blockers alone [10]. Baseline prostate volume and serum PSA levels in patients with BPH did not affect the efficacy of alpha-blockers, while alpha-blockers did not affect prostate volume or serum PSA levels. The results summarized by the American Urological Association’s BPH Guidelines Development Committee using a special Bayesian technique showed that the clinical efficacy of various alpha-blockers was similar, with some differences in side effects. For example, the incidence of cardiovascular system side effects caused by tamsulosin is low, but the incidence of retrograde ejaculation is high [11]. (4) Alpha-blocker therapy for acute urinary retention: the results of the clinical study showed that the chances of successful urinary catheter removal in patients with acute urinary retention BPH treated with alpha-blockers were significantly higher than those treated with placebo. (5) Side effects: common side effects include dizziness, headache, weakness, drowsiness, postural hypotension, retrograde ejaculation, etc. Postural hypotension is more likely to occur in elderly and hypertensive patients. (6) Treatment of overactive bladder (OAB) in patients with BPH: For patients with BPH who exhibit symptoms of OAB, treatment with alpha-blockers plus anticholinergic agents can be used. Clinical studies have shown that the addition of anticholinergic agents (e.g., tolterodine, solifenacin) to α-blockers in selective patients can significantly improve OAB symptoms and quality of life without increasing the risk of acute urinary retention [12-13]. If necessary, refer to the clinical guidelines for OAB. 2, 5-alpha reductase inhibitors (1) mechanism of action: 5-alpha reductase inhibitors inhibit the conversion of testosterone to dihydrotestosterone in the body, which in turn reduces the content of dihydrotestosterone in the prostate gland to reduce the size of the prostate gland and improve the therapeutic purpose of urinary difficulties. The 5-alpha reductase inhibitors currently used in China include Finasteride, Dutasteride and Epristeride. Finasteride and Epristeride are type II 5-alpha reductase inhibitors, and Dutasteride is a dual inhibitor of type I and type II 5-alpha reductase. (2) RECOMMENDATION: 5-alpha reductase inhibitors are indicated for the treatment of patients with BPH who have increased prostate volume with lower urinary tract symptoms. In patients at high risk for clinical progression of BPH, 5-alpha reductase inhibitors may be used to prevent clinical progression of BPH, such as the development of urinary retention or undergoing surgical treatment. Patients should be informed of the possible risk of clinical progression of BPH if they do not receive treatment, and due consideration should be given to the side effects and longer course of treatment associated with this type of therapy. (3) Clinical efficacy: the results of clinical trials have confirmed the effectiveness of finasteride in reducing prostate volume by 20% to 30%, improving patients’ symptom scores by about 15%, increasing urinary flow rate by about 1.3 to 1.6 ml/s, and reducing the risk of acute urinary retention and the need for surgical intervention in patients with BPH by about 50% [14-15], as well as significantly reducing the incidence of prostate cancer [16]. Studies have shown that finasteride is more effective in treating patients with larger prostate size and/or higher serum PSA levels [17]. The long-term efficacy of finasteride has been demonstrated, with results from randomized controlled trials showing maximum efficacy after 6 months of finasteride use. Efficacy continues to be stable over 6 years of continuous drug therapy [18]. Clinical studies have confirmed that dutasteride reduces prostate volume by 20-30%, improves patients’ symptom scores by about 20-30%, improves urinary flow rate by about 2.2-2.7 ml/s, reduces the risk of acute urinary retention and the need for surgical intervention in patients with BPH by 57% and 48%, respectively [19-21], and significantly reduces the incidence of prostate cancer [22]. Several studies have shown that finasteride reduces the incidence of hematuria in patients with BPH. The data of the study showed that the application of finasteride (5 mg/day for more than 4 weeks) prior to transurethral electrolysis of the prostate reduced intraoperative bleeding in patients with BPH with large prostate volume [23-24]. (4) Side effects: the most common side effects of 5-alpha reductase inhibitors include erectile dysfunction, abnormal ejaculation, low libido and others such as gynecomastia and mastalgia [25]. (5) 5-alpha reductase inhibitors affect serum PSA levels: 5-alpha reductase inhibitors reduce serum PSA levels, and continued use for one year can reduce PSA levels by 50%. For patients applying 5-alpha reductase inhibitors, doubling their serum PSA levels does not affect their efficacy in detecting prostate cancer [26]. 3.Combination therapy Combination therapy refers to the joint application of α-blockers and 5-α reductase inhibitors for the treatment of BPH. (1) Recommendation: combination therapy is suitable for BPH patients with increased prostate size and lower urinary tract symptoms. patients with a greater risk of clinical progression of BPH are more suitable for combination therapy. The risk of clinical progression of BPH in a specific patient, the patient’s willingness, economic status, and the increase in costs associated with combination therapy should be fully considered before adopting combination therapy. (2) Clinical efficacy: Current research results have confirmed the long-term clinical efficacy of combination therapy, and the results of MTOPS [10] and CombAT [21] show that the combination of alpha-blockers and 5-alpha reductase inhibitors significantly reduces the risk of clinical progression of BPH, and the long-term efficacy of the combination therapy is better than that of single-agent therapy. 4, phytotherapeutic agents (phytotherapeutic agents) such as Pulsatilla is suitable for the treatment of BPH and related lower urinary tract symptoms. Some studies suggest that their efficacy is comparable to that of 5-α reductase inhibitors and α-blockers, without significant side effects [27-28]. However, the mechanism of action of botanical agents is complex, and it is difficult to determine the correlation between the biological activity of specific components and their efficacy. Large-scale randomized controlled clinical studies based on the principles of evidence-based medicine have a positive significance in further promoting the clinical application of botanical agents in the treatment of BPH. Traditional Chinese medicine (TCM) has made indelible contributions to the development of China’s medical and healthcare programs and the health of the Chinese nation. At present, there are many types of Chinese medicines used in the clinical treatment of BPH, please refer to the recommendations of the Society of Traditional Chinese Medicine or the Society of Integrative Medicine to carry out the treatment. 6. Individualized principle of drug therapy BPH drug therapy should be based on the patient’s symptoms, risk of progression and response to treatment, and individualized treatment should be considered in terms of drug dosage, course of treatment, and combination of drugs. Different individuals have different responses to a-blockers, and there are also differences in the therapeutic dose and course of treatment. In terms of therapeutic dose, dose titration can be used to determine the optimal therapeutic dose of a-blockers [29-30]; in terms of the course of treatment, the combination of α-blockers + 5α-reductase inhibitors is used for patients with obvious symptoms and a greater risk of clinical progression, and it is recommended that the course of treatment be no shorter than one year [31]. Second, surgical treatment 1, the purpose of surgical treatment BPH is a clinically progressive disease, some patients ultimately need surgical treatment to relieve the lower urinary tract symptoms and its impact on the quality of life and complications. 2, Indications for surgical treatment Surgical treatment can be chosen when the lower urinary tract symptoms of severe BPH have significantly affected the patient’s quality of life [1,2], especially when the effect of drug treatment is not good or the patient refuses to accept drug treatment, surgical treatment can be considered. Surgical treatment is recommended when BPH leads to the following complications: ① recurrent urinary retention (inability to urinate after at least one extubation or two urinary retentions); ② recurrent hematuria, ineffective treatment with 5α reductase inhibitors; ③ recurrent urinary tract infections; ④ bladder stones; and ⑤ secondary upper urinary tract hydrops (with or without renal impairment). Surgical treatment should be considered in BPH patients with combined large bladder diverticulum, inguinal hernia, severe hemorrhoids or prolapse, and in those who clinically judge that it is difficult to achieve therapeutic results without relieving lower urinary tract obstruction. Measurement of residual urine volume has a certain reference value for the degree of lower urinary tract obstruction due to BPH, but due to the instability of repeated measurements, inter-individual variation, and the inability to distinguish lower urinary tract obstruction from bladder weakness, it is not considered possible to determine the upper limit of residual urine volume that can be used as an indication for surgery. However, surgical treatment should be considered in patients with BPH who have a significant increase in residual urine to the point of overflow incontinence. The choice of treatment by the urologist should respect the patient’s wishes. The choice of surgical treatment should take into account the surgeon’s personal experience, the patient’s opinion, the size of the prostate gland, as well as the patient’s concomitant diseases and general condition. 3, surgical treatment modalities Surgical treatment of BPH includes general surgical treatment, laser treatment and other treatment modalities. the effect of BPH treatment is mainly reflected in the patient’s subjective symptoms (e.g., I-PSS score) and objective indicators (e.g., the maximum urinary flow rate) of change. The evaluation of treatment methods, on the other hand, should consider comprehensive factors such as treatment effects, complications, and socioeconomic conditions. (1) General surgery: classical surgical methods include transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP), and open prostate removal. TURP is still the “gold standard” for BPH treatment [1,2]. Various surgical approaches have similar or comparable outcomes to TURP, but with different indications and complications. As alternative treatments to TURP or TUIP, transurethral electrovaporization of the prostate (TUVP) and bipolar transurethral PlasmaKinetic Prostatectomy (TUPKinetic) are the most effective surgical procedures. Prostatectomy (TUPKP) are also currently used for surgical treatment. All of the above treatments are able to improve more than 70% of lower urinary tract symptoms in patients with BPH. 1) TURP is mainly used to treat BPH patients with a prostate volume of less than 80 ml, and skilled operators can appropriately relax the restriction on prostate volume. The incidence of hemodilatation and dilutional hyponatremia (transurethral electrolysis syndrome, TUR-Syndrome) due to excessive absorption of flushing fluid is about 2%, and the risk factors are high intraoperative bleeding, long operative time, and large prostate volume, etc.[1,2] Prolongation of the TURP operation time increases the risk of transurethral electrolysis syndrome significantly. The chance of needing blood transfusion is about 2% to 5%. The incidence of various postoperative complications[1,2-6]: urinary incontinence is about 1% to 2.2%, retrograde ejaculation is about 65% to 70%, and bladder neck contracture is about 4%. Urethral stricture is about 3.8%. 2)TUIP is indicated for patients with prostate volume less than 30 g and without mesophyll hyperplasia.The degree of improvement of lower urinary tract symptoms in patients after TUIP treatment is similar to that of TURP[3,6]. Compared with TURP, there are fewer complications, lower risk of bleeding and need for blood transfusion, lower incidence of retrograde ejaculation, shorter operative time and hospital stay. However, the rate of long-term recurrence is higher than TURP [3]. 3) Open prostatectomy is mainly suitable for patients with prostate volume greater than 80 ml, especially when combined with bladder stones, or combined with bladder diverticulum need to be operated together [4,5]. Commonly used surgical procedures are suprapubic prostatectomy and retropubic prostatectomy. The need for blood transfusion is higher than that of TURP.The incidence of various postoperative complications [4,5]: urinary incontinence is about 1%, retrograde ejaculation is about 80%, bladder neck contracture is about 1.8%, and urethral stricture is about 2.6%.The incidence of postoperative complications is about 2.6%, and the incidence of postoperative complications is about 2.6%. The effect on erectile function may not be related to the procedure. 4) TUVP is indicated for BPH patients with poor coagulation and small prostate size. It is an alternative to TUIP or TURP with better hemostasis compared to TURP [6]. Long-term complications are similar to TURP. 5) TUPKP is a transurethral resection of the prostate using a plasma bipolar electrocautery system and is performed in a similar manner to monopolar TURP. Saline is used as the intraoperative irrigation fluid. Intraoperative bleeding and the occurrence of TURS are reduced [6-7]. (2) Laser therapy: the use of lasers in the treatment of BPH is gradually increasing. Currently, the commonly used types of lasers are holmium laser (Ho:YAG), green laser (KTP:YAG or LBO:YAG), and thulium laser (Tm:YAG). The therapeutic effect of the laser is related to the histological effect of its wavelength and power, and it can pluck out, vaporize, and vaporize and cut the prostate. 1) Holmium laser has a wavelength of 2140nm and a tissue coagulation depth of 0.5-1mm, allowing tissue vaporization and cutting. Holmium Laser Enucleation of the prostate (HoLEP) has a resection range theoretically the same as that of open surgery, and the efficacy and long-term complications are comparable to those of TURP [8-9]. Bladder injury should be avoided when crushing the resected tissue.HoLEP has a longer learning curve. 2) Green laser with a wavelength of 532 nm and a tissue coagulation depth of about 1 mm is used to vaporize the prostate, also known as photoselective vaporization of the prostate (PVP).PVP is suitable for small and medium-sized patients with BPH, and the near-term postoperative efficacy is comparable to that of TURP[10].Postoperative PVP cannot PVP cannot provide pathologic specimens. 3) Thulium laser with a wavelength of 2013 nm, also known as 2-micron laser, is mainly used to vaporize and cut the prostate. The short-term efficacy is comparable to that of TURP [11-12]. The observation of long-term efficacy is still lacking. (3) Other treatments 1) Transurethral Microwave Therapy (TUMT): it can partially relieve urinary flow rate and LUTS symptoms in BPH patients. It is suitable for patients who are ineffective in drug treatment (or unwilling to take long-term medication) and unwilling to undergo surgery, as well as high-risk patients with recurrent urinary retention who cannot undergo surgery [13]. 2) Prostate stents (Stents) are metal (or polyurethane) devices placed endoscopically in the urethra of the prostate [14]. It can relieve lower urinary tract symptoms due to BPH. It is only indicated as an alternative treatment to catheterization in high-risk patients with recurrent urinary retention who cannot undergo surgery. Common complications include stent displacement and calcification, stent occlusion, infection, and chronic pain. Transurethral prostatic balloon dilatation still has some application. There is no clear evidence to support high-energy focused ultrasound, chemical ablation therapy with prostate alcohol injection as an effective option for BPH treatment. Third, the treatment of urinary retention in patients with BPH 1, acute urinary retention When acute urinary retention occurs in patients with BPH, the urine should be drained promptly. The first choice is to place a catheter, and a suprapubic cystostomy is feasible for those who fail to place it [15]. The catheter is usually left in place for 3 to 7 days, and the success rate of extubation can be improved if α-blockers are taken at the same time. Those with successful extubation may continue to receive BPH medication. After the extraction of the catheter recurrence of urinary retention, should be scheduled for surgical treatment. 2.Chronic urinary retention BPH long-term bladder outlet obstruction, chronic urinary retention can lead to ureteral dilatation, hydronephrosis and renal function impairment. If renal function is normal, surgical treatment is feasible; if renal insufficiency occurs, bladder urine should be drained first, and then elective surgery should be performed after renal function is restored to normal or near normal, the condition is stable, and the general condition improves significantly.