What are the treatment options for erectile dysfunction (ED) with benign prostatic hyperplasia (BPH) when low-dose Tadalafil (Cialis) is ineffective?

From the Guidelines

If low-dose daily tadalafil (typically 5mg) isn't effectively managing both erectile dysfunction (ED) and benign prostatic hyperplasia (BPH), the most effective alternative approach is to increase to on-demand tadalafil (10-20mg) before sexual activity while adding a separate BPH medication like an alpha-blocker such as tamsulosin (0.4mg daily) or alfuzosin (10mg daily), as recommended by the American Urological Association guideline 1. This approach is based on the strongest and most recent evidence, which suggests that PDE5 inhibitors, including tadalafil, are effective in treating ED, and that alpha-blockers can help alleviate BPH symptoms. Some key points to consider when treating ED with BPH include:

• The dose of tadalafil may need to be titrated to provide optimal efficacy, as recommended by the AUA guideline 1.
• Combination therapy with an alpha-blocker plus a 5-alpha reductase inhibitor like finasteride (5mg daily) or dutasteride (0.5mg daily) for BPH, while using sildenafil (50-100mg), vardenafil (10-20mg), or avanafil (100-200mg) as needed for ED, may be considered if the initial approach fails.
• It's essential to discuss these options with your doctor, as medication interactions can occur, particularly between ED medications and alpha-blockers, potentially causing dangerous drops in blood pressure.
• The evidence is insufficient to compare the efficacy and adverse effects of different PDE-5 inhibitors for the treatment of ED, and individual preferences, ease of use, and cost of medication are reasonable criteria to help select a treatment 1. However, the most recent and highest quality study, the AUA guideline 1, provides the strongest evidence for the recommended approach.

From the FDA Drug Label

Tadalafil for once daily use resulted in statistically significant improvements in the total IPSS and in the EF domain of the IIEF questionnaire. Tadalafil 5 mg for once daily use also resulted in statistically significant improvement in SEP3. In the 404 patients who had both ED and BPH at baseline, changes in erectile function were assessed as key secondary endpoints using the EF domain of the IIEF questionnaire. Tadalafil with finasteride (N=203) was compared to placebo with finasteride (N=201). A statistically significant improvement from baseline (tadalafil/finasteride 13. 7, placebo/finasteride 15.1) was observed at week 4 (tadalafil/finasteride 3.7, placebo/finasteride -1.1; p less than .001), week 12 (tadalafil/finasteride 4.7, placebo/finasteride 0.6; p less than .001), and week 26 (tadalafil/finasteride 4.7, placebo/finasteride 0.0; p less than .001).

If low-dose tadalafil is not working for treating erectile dysfunction with BPH, increasing the dose or adding another medication such as finasteride may be considered.

• Tadalafil 5 mg once daily has been shown to be effective in treating ED and BPH symptoms.
• Combination therapy with tadalafil and finasteride has been shown to be effective in treating BPH symptoms and ED. However, it is essential to consult a healthcare provider to determine the best course of treatment, as they will assess the individual's specific situation and medical history before making any recommendations 2.

From the Research

Treatment Options for Erectile Dysfunction with BPH

• If low-dose tadalafil is not working, there are several alternative treatment options available for erectile dysfunction (ED) with benign prostatic hyperplasia (BPH) 3, 4, 5, 6.
• Tadalafil 5 mg once daily has been shown to be effective in treating both ED and the signs and symptoms of BPH 3, 4, 6.
• The mechanism of tadalafil in improving lower urinary tract symptoms (LUTS) associated with BPH is thought to be related to alterations in nitric oxide levels, Rho-associated protein kinase deactivation, and reductions in pelvic atherosclerosis 5.

Alternative Treatment Options

• Other phosphodiesterase type 5 (PDE5) inhibitors, such as sildenafil and vardenafil, may also be effective in treating ED with BPH, although tadalafil is the only PDE5 inhibitor approved for the treatment of signs and symptoms of BPH 5.
• Alpha-adrenergic blockers, such as tamsulosin, may also be used to treat LUTS associated with BPH, although they may have a negative impact on sexual function 7.
• Minimally invasive procedures, such as transurethral incision of the prostate, electrovaporisation, and laser prostatectomy, may also be effective in treating LUTS associated with BPH 7.

Considerations for Treatment

• The choice of treatment for ED with BPH should take into account the patient's preference, medical history, and the severity of their symptoms 7, 6.
• Concomitant use of medications, such as nonselective α-adrenergic antagonists, nitrates, and cytochrome P450 inhibitors, should be assessed for possible drug interactions when using tadalafil 5.
• Potential adverse drug events, such as back pain, dyspepsia, headache, and dizziness, should be monitored when using tadalafil 5.