What non-surgical intervention is most likely to be effective for a 66-year-old gentleman with benign prostatic hyperplasia (BPH) and persistent lower urinary tract symptoms (LUTS), including nocturia, urinary frequency, incomplete emptying, and reduced urinary flow, despite six months of alpha-blocker therapy?

From the Guidelines

The addition of finasteride to the current alpha blocker regimen is most likely to be the effective non-surgical intervention for this 66-year-old gentleman with persistent BPH symptoms. Finasteride works by inhibiting the enzyme 5-alpha reductase, which converts testosterone to dihydrotestosterone (DHT), the hormone primarily responsible for prostate growth. By reducing DHT levels, finasteride can shrink the prostate over time (typically 3-6 months) and improve urinary symptoms, as supported by the American Urological Association guideline on the management of benign prostatic hyperplasia 1. The combination therapy of an alpha blocker (which relaxes smooth muscle in the prostate and bladder neck) with finasteride (which reduces prostate size) provides complementary mechanisms of action that are more effective than either medication alone for men with enlarged prostates, as demonstrated in a 5-year study 1.

The typical dosage of finasteride is 5mg daily, and the patient should be informed that it may take several months to experience the full benefit. Side effects may include decreased libido, erectile dysfunction, and reduced ejaculate volume, as reported in the study by the American Society of Clinical Oncology/American Urological Association 1. Regular follow-up is important to assess symptom improvement and monitor for side effects.

Some key points to consider when prescribing finasteride include:

• Finasteride is effective in reducing the risk of acute urinary retention and the need for BPH-related surgery, especially in patients with larger prostates or higher PSA values 1.
• The combination of an alpha-adrenergic receptor blocker and a 5 alpha-reductase inhibitor has been found to be more effective in relieving and preventing the progression of symptoms than alpha-blocker monotherapy in a 5-year study 1.
• Patients most likely to benefit from combination therapy are those with a higher baseline risk of progression, such as those with larger glands and higher PSA values 1.

The other options listed, such as phenazopyridine, Bactrim, indwelling catheter, and saw palmetto, would not address the underlying prostate enlargement causing his obstructive and irritative urinary symptoms. Phenazopyridine is a urinary analgesic that can help with discomfort, but it does not treat the underlying condition. Bactrim is an antibiotic that is used to treat urinary tract infections, but it is not indicated for BPH. An indwelling catheter may be necessary in some cases of urinary retention, but it is not a treatment for BPH. Saw palmetto is a herbal supplement that has been studied for BPH, but its effectiveness is not well established, and it is not recommended as a first-line treatment 1.

From the FDA Drug Label

1.1 Monotherapy Finasteride tablets are indicated for the treatment of symptomatic benign prostatic hyperplasia (BPH) in men with an enlarged prostate to:

• Improve symptoms
• Reduce the risk of acute urinary retention
• Reduce the risk of the need for surgery including transurethral resection of the prostate (TURP) and prostatectomy.

1. 1 Monotherapy Finasteride tablets 5 mg/day was initially evaluated in patients with symptoms of BPH and enlarged prostates by digital rectal examination in two 1-year, placebo-controlled, randomized, double-blind studies and their 5-year open extensions Patients in A Long-Term Efficacy and Safety Study had moderate to severe symptoms at baseline (mean of approximately 15 points on a 0 to 34 point scale). Patients randomized to finasteride tablets who remained on therapy for 4 years had a mean (± 1 SD) decrease in symptom score of 3.3 (± 5. 8) points compared with 1.3 (± 5.6) points in the placebo group.

The most likely effective non-surgical intervention for this patient is the addition of finasteride to the current drug regimen.

• Finasteride has been shown to improve symptoms of BPH, reduce the risk of acute urinary retention, and reduce the risk of the need for surgery 2.
• The patient's symptoms, including frequent need to urinate, nocturia, and incomplete emptying, are consistent with BPH and may be improved with finasteride therapy.
• The patient's enlarged prostate, as indicated by the digital rectal examination, is also consistent with BPH and may respond to finasteride treatment 2.

From the Research

Treatment Options for BPH

The patient has been experiencing symptoms of Benign Prostatic Hyperplasia (BPH) despite six months of alpha-blocking therapy. The symptoms include frequent need to urinate, nocturia, daily urinary frequency, incomplete emptying, and reduced urinary flow.

Non-Surgical Interventions

The patient is seeking non-surgical interventions to manage his condition. The options provided are:

• Addition of finasteride to the current drug regimen
• Initiation of phenazopyridine therapy
• Initiation of Bactrim therapy
• Placement of an indwelling catheter
• Saw palmetto supplementation

Efficacy of Finasteride

Studies have shown that finasteride, a 5-alpha reductase inhibitor, is effective in reducing prostate volume, improving urinary flow rates, and decreasing symptom scores in patients with BPH 3, 4, 5, 6, 7. Finasteride works by inhibiting the conversion of testosterone to dihydrotestosterone, a hormone that promotes prostatic growth.

Comparison of Options

• The addition of finasteride to the current drug regimen is likely to be effective in managing the patient's symptoms, as it has been shown to improve urinary flow rates and reduce prostate volume 3, 4, 5, 6, 7.
• Phenazopyridine therapy is not typically used to treat BPH, but rather to relieve urinary tract pain and discomfort.
• Bactrim therapy is an antibiotic and is not typically used to treat BPH.
• Placement of an indwelling catheter is a surgical intervention and is not a suitable option for this patient.
• Saw palmetto supplementation has been studied as a potential treatment for BPH, but its efficacy is not well established, and it is not a recommended treatment option by the majority of the studies.

Key Points

• Finasteride is a well-established treatment option for BPH, with a proven track record of reducing prostate volume and improving urinary flow rates 3, 4, 5, 6, 7.
• The patient's symptoms, including frequent need to urinate, nocturia, and reduced urinary flow, are consistent with BPH and may be improved with finasteride therapy.
• The addition of finasteride to the current drug regimen is a suitable option for this patient, as it is a non-surgical intervention that has been shown to be effective in managing BPH symptoms.