Tadalafil for Nocturia Management
Introduction to Tadalafil
- The American Urological Association recommends tadalafil 5 mg daily as a treatment option for patients with LUTS/BPH, with moderate recommendation strength and Grade B evidence 1
- Tadalafil 5 mg once daily is FDA-approved for treating signs and symptoms of BPH, which includes nocturia as a storage symptom, and can simultaneously treat both erectile dysfunction and BPH symptoms when both conditions coexist 1
- Tadalafil works by relaxing smooth muscle in the prostate and bladder, improving urinary flow and reducing storage symptoms 1
Diagnosis and Assessment
- Before attributing nocturia solely to BPH, a frequency-volume chart should be used to exclude nocturnal polyuria, which requires different management 2, 3
- Nocturnal polyuria (nighttime urine production >33% of 24-hour output) requires fluid restriction and potentially desmopressin, not tadalafil 2, 3
- Global polyuria (24-hour output >3 liters) requires lifestyle modification and addressing underlying causes 2, 3
Contraindications and Safety
- Never prescribe tadalafil if the patient takes nitrates in any form—this combination can cause fatal hypotension 1
- Tadalafil is also contraindicated with guanylate cyclase stimulators like riociguat 4
- Assess cardiovascular fitness before prescribing, and refer to cardiology if unable to perform moderate physical activity or if cardiovascular risk is indeterminate 4
Dosing and Administration
- The only recommended dose for BPH/nocturia is tadalafil 5 mg once daily—higher doses do not provide additional benefit for urinary symptoms 1
- Take at approximately the same time each day, with or without food 1
Combination Therapy
- Do not combine tadalafil 5 mg with alpha-blockers (tamsulosin, alfuzosin, doxazosin) for LUTS/BPH—this offers no additional symptom benefit over either agent alone and significantly increases side effects, particularly hypotension 1, 5
- The American Urological Association explicitly recommends against this combination 1, 5
Guidelines and Recommendations
- The European Association of Urology guidelines note that while tadalafil improves LUTS, the specific impact on nocturia requires further study with voiding diaries 6