What is the most appropriate treatment for a 69-year-old male with benign prostatic hyperplasia (BPH) symptoms, including frequent urination, nocturia, post-void dribbling, and a weak urinary stream, with an enlarged prostate and a prostate-specific antigen (PSA) level indicating elevated PSA?

Treatment of Lower Urinary Tract Symptoms in a 69-Year-Old Male with BPH

The most appropriate treatment for this patient with moderate LUTS (AUA-SI score 15/35), enlarged prostate, and elevated PSA (4.6 ng/mL) is to initiate combination therapy with finasteride and tamsulosin. 1, 2

Assessment of Patient Presentation

This patient presents with classic symptoms of BPH:

• Frequent urination
• Nocturia (2-3 times per week)
• Post-void dribbling
• Weak urinary stream
• Moderate symptom severity (AUA-SI score 15/35)
• Enlarged prostate on DRE
• Elevated PSA (4.6 ng/mL)
• No evidence of infection, diabetes, or kidney damage

Treatment Algorithm

Step 1: Determine Appropriate Pharmacotherapy

• Patient characteristics supporting combination therapy:
  • Moderate symptoms (AUA-SI score 15/35)
  • Enlarged prostate on DRE
  • Elevated PSA (4.6 ng/mL) indicating prostatic enlargement
  • Age 69 years with likely long-term disease progression risk

Step 2: Select Specific Medications

• Alpha blocker (tamsulosin):

  • Provides rapid symptom relief (within days to weeks)
  • Relaxes smooth muscle in prostate and bladder neck
  • Improves both storage and voiding symptoms
  • Better safety profile than non-selective alpha blockers 3

• 5-alpha reductase inhibitor (finasteride):

  • Indicated for patients with enlarged prostates (confirmed by DRE) 2
  • Reduces prostate size over time (3-6 months)
  • Decreases risk of disease progression
  • Reduces risk of acute urinary retention by 67% 4
  • Reduces need for BPH-related surgery by 64% 4

Evidence Supporting This Approach

The American Urological Association guidelines strongly recommend combination therapy of alpha blockers and 5-ARIs for patients with enlarged prostates and moderate-to-severe symptoms (Strong Recommendation; Evidence Level: Grade A) 1. This approach provides both immediate symptom relief (alpha blocker) and long-term disease modification (5-ARI).

Finasteride is specifically indicated for "treatment of symptomatic benign prostatic hyperplasia in men with an enlarged prostate" 2. The FDA label explicitly states that "finasteride tablets administered in combination with the alpha-blocker doxazosin is indicated to reduce the risk of symptomatic progression of BPH" 2.

Why Other Options Are Less Appropriate

1. Alpha blocker monotherapy (tamsulosin alone):

   • Would not address the enlarged prostate or reduce long-term progression risk
   • Patient has clear indications for 5-ARI (enlarged prostate, elevated PSA)

2. Surgical referral:

   • Premature without trial of medical therapy
   • No indications of severe complications requiring immediate surgery
   • No evidence of urinary retention, renal insufficiency, recurrent UTIs, or bladder stones

3. Tadalafil and silodosin:

   • No evidence supporting this specific combination
   • Tadalafil is indicated for BPH but typically used alone or when erectile dysfunction is also present

4. Alfuzosin and vibegron:

   • No evidence supporting this specific combination for initial therapy
   • Vibegron (beta-3 agonist) is typically added when storage symptoms persist despite alpha blocker therapy

Monitoring and Follow-up

• Schedule follow-up in 4-6 weeks to assess initial symptom improvement
• Evaluate for side effects:
  • Tamsulosin: dizziness, rhinitis, abnormal ejaculation
  • Finasteride: sexual side effects, decreased libido, gynecomastia
• Monitor PSA (remember to double the value if on finasteride)
• Assess symptom improvement using AUA-SI score
• Measure post-void residual volume

Important Considerations and Cautions

• Inform patient that finasteride takes 3-6 months for full effect
• Warn about sexual side effects of finasteride
• Advise that PSA levels will decrease by approximately 50% after 6 months on finasteride
• Inform patient about risk of intraoperative floppy iris syndrome with tamsulosin if cataract surgery is planned
• Counsel on lifestyle modifications: limiting evening fluid intake, reducing caffeine and alcohol consumption

By initiating combination therapy with finasteride and tamsulosin, this patient will receive both immediate symptom relief and long-term protection against BPH progression, reducing his risk of complications such as acute urinary retention and need for surgery.