Benign Prostatic Hyperplasia (BPH) Treatment Guidelines

Introduction to BPH Treatment

The American Urological Association recommends alpha blockers as the first-line medication treatment for BPH, with 5-alpha reductase inhibitors (5-ARIs) recommended for men with demonstrable prostatic enlargement 1

Alpha blockers are the cornerstone of medical therapy for BPH due to their rapid onset of action and effectiveness in symptom relief, with five alpha blockers (alfuzosin, doxazosin, silodosin, tamsulosin, and terazosin) recommended as treatment options for moderate to severe LUTS/BPH 1
All five alpha blockers have similar clinical effectiveness, producing on average a 4-7 point improvement in IPSS compared to 2-4 points with placebo 1, 2
The choice of alpha blocker should be based on patient age, comorbidities, and different adverse event profiles 1
Alpha blockers work by inhibiting alpha1-adrenergic-mediated contraction of prostatic smooth muscle, relieving bladder outlet obstruction 3

Patients planning cataract surgery should be informed about the risk of intraoperative floppy iris syndrome (IFIS) associated with alpha blockers 1

5-ARIs are recommended for men with larger prostates and are effective in preventing disease progression, with 5-ARI monotherapy (finasteride, dutasteride) recommended for patients with LUTS/BPH with prostatic enlargement as judged by prostate volume, PSA, or palpable prostate enlargement 1, 4
5-ARIs work by blocking the conversion of testosterone to dihydrotestosterone, leading to prostate volume reduction 3

Sexual side effects are common with 5-ARIs, including impotence, decreased libido, and decreased volume of ejaculate 3, 4

5-ARI in combination with an alpha blocker should be offered only to patients with demonstrable prostatic enlargement (prostate volume >30cc, PSA >1.5ng/mL, or palpable enlargement) 4
Combination therapy may provide additional benefits for selected patients, with two large studies (MTOPS and CombAT) showing statistically significant reductions in clinical progression with combination therapy over monotherapy 4

For patients with LUTS/BPH, regardless of erectile dysfunction status, 5mg daily tadalafil should be discussed as a treatment option, producing a modest improvement in IPSS compared to placebo, with a mean change of -1.74 points 4

Physicians should prescribe an oral alpha blocker prior to a voiding trial for patients with acute urinary retention (AUR) related to BPH, with patients completing at least three days of alpha blocker therapy before attempting a trial without catheter (TWOC) 5
Alpha blockers like alfuzosin and tamsulosin improve TWOC success rates 5

For initial treatment of moderate to severe LUTS/BPH, start with alpha blocker monotherapy for most patients, consider 5-ARI monotherapy if prostate is enlarged, and consider tadalafil 5mg daily, particularly if erectile dysfunction is present 1, 4
For patients with inadequate response to alpha blocker monotherapy, add 5-ARI if prostate is enlarged, consider adding anticholinergic agent if storage symptoms predominate, and consider adding beta-3-agonist if storage symptoms predominate 4

Failing to assess prostate size before initiating 5-ARI therapy, as 5-ARIs are only effective for enlarged prostates 1
Not informing patients about sexual side effects of 5-ARIs, and not checking post-void residual (PVR) before and during treatment with anticholinergics 5
Combining tadalafil with alpha blockers, which provides no additional benefit but increases side effect risk, and not informing ophthalmologists about alpha blocker use before cataract surgery 1, 4