Treatment of Benign Prostatic Hyperplasia (BPH)

Introduction to BPH Treatment

The American Urological Association recommends tamsulosin as the preferred treatment for BPH alone, while terazosin is recommended when a patient has both BPH and hypertension requiring treatment, due to its ability to address both conditions simultaneously 1

Tamsulosin is a selective alpha-1A adrenergic receptor antagonist, providing "uroselectivity" that targets receptors primarily in the prostate, with minimal blood pressure effects 1
Terazosin is a non-selective alpha-1 adrenergic receptor antagonist that affects both urinary and vascular smooth muscle, producing significant blood pressure reduction in hypertensive patients 1

For patients with BPH only, tamsulosin 0.4 mg daily is preferred due to its minimal blood pressure effects and lower risk of orthostatic hypotension 1
For patients with both BPH and untreated hypertension, terazosin starting at 1 mg daily, titrating to 5-10 mg daily, is recommended to address both conditions simultaneously 1
For patients with BPH and controlled hypertension on other medications, tamsulosin can be used if blood pressure is well-controlled, while terazosin can be used if additional blood pressure control is desired 1
The American Urological Association recommends terazosin as a treatment option for BPH, with a maximum effective dose of 10 mg typically being the target dose for most patients with BPH 2, 1

Terazosin should be started at 1 mg at bedtime, with gradual dose escalation to minimize first-dose hypotension, and a typical effective dose of 5-10 mg daily for BPH 1
Tamsulosin should be started at 0.4 mg once daily, with no titration required, and may be increased to 0.8 mg if needed after 2-4 weeks 1

Terazosin has a higher risk of orthostatic hypotension, dizziness, asthenia, headache, and risk of syncope, particularly during initiation or dose escalation 1, 2
Tamsulosin has a lower risk of cardiovascular side effects, but a higher incidence of ejaculatory dysfunction, headache, rhinitis, and dizziness 1, 2
Patients should be monitored for blood pressure during initiation and dose adjustments with terazosin, and for symptom improvement at 2-4 weeks with either medication 1
Common side effects of terazosin include orthostatic hypotension, dizziness, tiredness (asthenia), ejaculatory problems, and nasal congestion 2
The risk of syncope is rare (0.6% of patients), most likely during initiation or dose escalation 2

Terazosin has been shown to improve BPH symptoms, with a 4-6 point improvement in AUA Symptom Index 2
Alfuzosin, doxazosin, tamsulosin, and terazosin are all considered appropriate treatment options for LUTS secondary to BPH with equal clinical effectiveness 2
Tamsulosin appears to have a lower probability of orthostatic hypotension but higher probability of ejaculatory dysfunction compared to terazosin 2

Tamsulosin can cause intraoperative floppy iris syndrome, which can complicate cataract surgery, and should be taken 30 minutes after the same meal each day 1
Terazosin may have beneficial effects on lipid profiles, increasing HDL and reducing LDL 1
In men with hypertension and cardiac risk factors, terazosin monotherapy may be insufficient for optimal hypertension management and separate antihypertensive therapy may be required 2