What are the treatment options for Benign Prostatic Hyperplasia (BPH) that preserve sexual function?

BPH Treatment Options That Preserve Sexual Function

Tamsulosin is the most effective first-line treatment for BPH that minimizes impact on sexual function compared to other treatment options. 1, 2

First-Line Therapy: Alpha Blockers

• Alpha blockers are the first-line pharmacological treatment for BPH, providing rapid symptom relief with a 4-6 point improvement in AUA Symptom Index within 2-4 weeks 1, 3
• Among alpha blockers, tamsulosin has the lowest risk of orthostatic hypotension but may have a higher probability of ejaculatory dysfunction compared to other alpha blockers 1, 2
• Tamsulosin is a selective alpha-1A receptor blocker that can be initiated without dose titration and has minimal effects on blood pressure, making it safer for elderly patients 1, 4
• Common side effects of tamsulosin include asthenia (tiredness), nasal congestion, and ejaculatory problems 2, 5

Second-Line Therapy: 5-Alpha Reductase Inhibitors

• 5-alpha reductase inhibitors (finasteride, dutasteride) are appropriate for patients with LUTS associated with demonstrable prostatic enlargement (prostate volume >30cc) 1, 6
• Finasteride produces a 3-point improvement in AUA Symptom Index but requires 6-12 months for maximum effect 1, 3
• Sexual side effects of 5-alpha reductase inhibitors include decreased libido, ejaculatory dysfunction, and erectile dysfunction 1, 6
• Finasteride is ineffective in patients without enlarged prostates and should not be used in this population 1, 4

Combination Therapy Considerations

• The combination of 5-alpha reductase inhibitors with alpha blockers should only be offered to patients with demonstrable prostatic enlargement (prostate volume >30cc on imaging, PSA >1.5ng/mL, or palpable prostate enlargement on DRE) 2, 6
• Combination therapy may increase the risk of sexual side effects compared to monotherapy 6, 7

Surgical Options and Their Impact on Sexual Function

• Surgery is recommended for patients with refractory urinary retention, renal insufficiency, recurrent UTIs, recurrent gross hematuria, or bladder stones due to BPH 8
• Transurethral resection of the prostate (TURP) is effective but carries risk of sexual dysfunction, incontinence, and bleeding 9
• Less invasive surgical procedures using thermal microwave or laser energy have fewer complications but may require retreatment more often 9

Clinical Decision Algorithm for Preserving Sexual Function

1. For patients with mild to moderate symptoms without prostate enlargement:

   • Start with tamsulosin 0.4mg daily as it provides rapid symptom relief with minimal impact on blood pressure 1, 2
   • Monitor for ejaculatory dysfunction, which is the most common sexual side effect 2, 5

2. For patients with moderate to severe symptoms with prostate enlargement:

   • Consider tamsulosin first if sexual function preservation is a priority 2, 5
   • Consider finasteride only if prostate is enlarged (>30cc) and patient understands potential sexual side effects 1, 6

3. For patients with severe symptoms or complications:

   • Surgery may be necessary despite potential sexual side effects 8
   • Discuss newer, less invasive surgical options that may have fewer sexual side effects than traditional TURP 9

Important Clinical Pitfalls

• Patients undergoing cataract surgery should inform their ophthalmologist about tamsulosin use due to the risk of intraoperative floppy iris syndrome 2
• Alpha blockers should not be assumed to constitute optimal management of concomitant hypertension 1
• 5-alpha reductase inhibitors take 6-12 months for maximum effect and should not be used in patients without prostatic enlargement 1, 4
• Balloon dilation is not recommended as a treatment option for BPH due to inadequate results and significant failure rates 1