What are the pharmacological management options for Benign Prostatic Hyperplasia (BPH)?

Pharmacological Management of Benign Prostatic Hyperplasia (BPH)

Alpha blockers are the first-line pharmacological treatment for BPH, providing rapid symptom relief with a 4-6 point improvement in AUA Symptom Index, which patients perceive as meaningful. 1

First-Line Therapy: Alpha Blockers

• All four alpha blockers (tamsulosin, alfuzosin, doxazosin, and terazosin) demonstrate similar clinical effectiveness in improving lower urinary tract symptoms (LUTS) 1
• Tamsulosin has less effect on blood pressure compared to other alpha blockers, making it a safer option for elderly patients and those with hypertension 1
• Alpha blockers work by relaxing prostatic and bladder neck smooth muscle, providing relatively fast symptom relief 2
• Non-titratable alpha blockers (tamsulosin, alfuzosin) can be initiated without dose titration, while doxazosin and terazosin require dose titration to minimize first-dose hypotensive effects 1

Common Side Effects of Alpha Blockers:

• Orthostatic hypotension, dizziness, tiredness (asthenia), ejaculatory problems, and nasal congestion 3
• Tamsulosin appears to have a lower probability of orthostatic hypotension but a higher probability of ejaculatory dysfunction compared to other alpha blockers 3

Special Considerations:

• In patients with hypertension, doxazosin monotherapy was associated with a higher incidence of congestive heart failure than other antihypertensive agents, suggesting separate management of hypertension may be needed 3, 1
• Selective alpha blockers (alfuzosin, tamsulosin) act predominantly on the prostate and have less effect on blood pressure 2

Second-Line Therapy: 5-Alpha Reductase Inhibitors

• 5-alpha reductase inhibitors (finasteride, dutasteride) are appropriate for patients with LUTS associated with demonstrable prostatic enlargement 3
• These medications reduce prostate size by blocking the conversion of testosterone to dihydrotestosterone 4
• Finasteride is indicated to improve symptoms, reduce the risk of acute urinary retention, and reduce the need for BPH-related surgery 5
• With finasteride, patients typically experience a 3-point improvement in the AUA Symptom Index, which is generally perceived as meaningful 3
• 5-alpha reductase inhibitors are ineffective in patients without enlarged prostates 3

Side Effects of 5-Alpha Reductase Inhibitors:

• Primarily sexually related adverse events including decreased libido, ejaculatory dysfunction, and erectile dysfunction 3
• These side effects are reversible and uncommon after the first year of therapy 3

Combination Therapy

• Finasteride administered in combination with the alpha-blocker doxazosin is indicated to reduce the risk of symptomatic progression of BPH 5
• The combination of an alpha blocker with a 5-alpha reductase inhibitor may be more effective than either medication alone for patients with larger prostates 5

Management of Acute Urinary Retention due to BPH

• The initial treatment for patients with acute urinary retention is catheterization followed by administration of an alpha blocker prior to attempting catheter removal 1
• Alpha blockers, particularly non-titratable ones like tamsulosin or alfuzosin, should be started and continued for at least 3 days before attempting a trial without catheter 1
• Alpha blockers significantly improve trial without catheter success rates (alfuzosin: 60% vs 39% for placebo; tamsulosin: 47% vs 29% for placebo) 1, 6
• If catheter removal fails after alpha blocker treatment, surgery is recommended 1

When to Consider Surgery

• Surgery is recommended for patients with refractory urinary retention who have failed at least one attempt at catheter removal 3, 7
• Surgery is indicated for patients with renal insufficiency, recurrent UTIs, recurrent gross hematuria, or bladder stones clearly due to BPH and refractory to other therapies 3, 7
• For patients who are not surgical candidates, options include intermittent catheterization, indwelling catheter, and prostatic stent placement 3, 7

Other Pharmacological Options

• Phytotherapeutic agents (e.g., Serenoa repens) have been used for their anti-androgenic and anti-estrogenic activities, though their efficacy is generally less than alpha blockers 4, 6

Important Clinical Pitfalls

• Balloon dilation is not recommended as a treatment option for BPH due to inadequate study results and significant failure rates over time 3, 7
• Alpha blockers should not be assumed to constitute optimal management of concomitant hypertension 3
• When prescribing PDE5 inhibitors (e.g., tadalafil) to patients on alpha blockers, caution is advised due to potential additive blood pressure-lowering effects 8
• 5-alpha reductase inhibitors should not be used in patients without prostatic enlargement as they are ineffective in this population 3