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

Treatment Options for 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 improvement. 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), producing on average a 4-6 point improvement in the AUA Symptom Index 2, 1
• When prescribing an alpha blocker, the choice should be based on patient age, comorbidities, and different adverse event profiles 2
• 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, 3
• Common side effects of alpha blockers include orthostatic hypotension, dizziness, tiredness (asthenia), ejaculatory problems, and nasal congestion 2, 1
• Tamsulosin appears to have a lower probability of orthostatic hypotension but a higher probability of ejaculatory dysfunction compared to other alpha blockers 2, 1

Dosing Considerations

• Doxazosin and terazosin require dose titration to minimize first-dose hypotensive effects, while tamsulosin and alfuzosin can be initiated without dose titration 1, 4
• Clinical data support the efficacy and safety of titrating patients to 8 mg of doxazosin, 0.8 mg of tamsulosin (from 0.4 mg), and 10 mg of terazosin 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 2, 1
• 5-ARIs should be used in patients with prostate volume >30cc on imaging, PSA >1.5ng/mL, or palpable prostate enlargement on digital rectal exam 2
• With finasteride, patients typically experience a 3-point improvement in the AUA Symptom Index 2, 1
• 5-alpha reductase inhibitors are ineffective in patients without enlarged prostates 2, 1
• Finasteride is indicated to:
  • Improve symptoms
  • Reduce the risk of acute urinary retention
  • Reduce the risk of the need for surgery including TURP and prostatectomy 5

Side Effects

• Primarily sexually related adverse events including decreased libido, ejaculatory dysfunction, and erectile dysfunction are common side effects of 5-alpha reductase inhibitors 2, 5
• In clinical trials, 3.7% of patients treated with finasteride discontinued therapy due to sexual function-related adverse reactions 5

Combination Therapy

• Finasteride administered in combination with the alpha-blocker doxazosin is indicated to reduce the risk of symptomatic progression of BPH 5
• 5-ARIs alone or in combination with alpha blockers are recommended to prevent progression of LUTS/BPH and reduce the risks of urinary retention and need for future prostate-related surgery 2
• Combination therapy may have more side effects than either medication alone, including asthenia, postural hypotension, peripheral edema, dizziness, decreased libido, rhinitis, abnormal ejaculation, impotence and abnormal sexual function 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 6
• Alpha blockers significantly improve trial without catheter success rates (alfuzosin: 60% vs 39% for placebo; tamsulosin: 47% vs 29% for placebo) 6
• Alpha blocker therapy should be continued for at least 3 days before attempting a trial without catheter 6
• If catheter removal fails after alpha blocker treatment, surgery is recommended 6

Clinical Pitfalls and Special Considerations

• In men with hypertension and cardiac risk factors, doxazosin monotherapy was associated with a higher incidence of congestive heart failure than other antihypertensive agents, suggesting separate management of hypertension may be needed 2, 1
• 5-alpha reductase inhibitors should not be used in patients without prostatic enlargement as they are ineffective in this population 2, 1
• When initiating alpha blocker therapy, patients with planned cataract surgery should be informed of the associated risks (Intraoperative Floppy Iris Syndrome) and be advised to discuss these risks with their ophthalmologists 2
• Balloon dilation is not recommended as a treatment option for BPH due to inadequate study results and significant failure rates over time 6