What are the best supplements for Benign Prostatic Hyperplasia (BPH)?

Best Supplements for Benign Prostatic Hyperplasia (BPH)

Direct Answer

There are no supplements recommended by major urological guidelines for the treatment of BPH—prescription medications (alpha blockers and 5-alpha reductase inhibitors) are the evidence-based treatments of choice. 1, 2

Evidence-Based Medical Treatments (Not Supplements)

The American Urological Association and European Association of Urology guidelines do not recommend supplements for BPH management. Instead, they recommend:

First-Line: Alpha Blockers

• Alpha blockers are the cornerstone of medical therapy for BPH due to rapid onset and effectiveness in symptom relief 2
• Five alpha blockers are recommended: alfuzosin, doxazosin, silodosin, tamsulosin, and terazosin 2
• All produce on average a 4-7 point improvement in symptom scores compared to 2-4 points with placebo 2
• Tamsulosin 0.4 mg once daily produces approximately 1.6 ml/s improvement in urinary flow rate (16% increase) compared to 0.6 ml/s with placebo 3
• Terazosin produces on average a 4-6 point improvement in AUA Symptom Index 4

Second-Line: 5-Alpha Reductase Inhibitors (5-ARIs)

• 5-ARIs (finasteride, dutasteride) are appropriate only for men with demonstrable prostatic enlargement (prostate volume >30cc, PSA >1.5 ng/mL, or palpable enlargement) 1, 2
• Finasteride produces an average 3-point improvement in AUA Symptom Index 1
• 5-ARIs are NOT appropriate for men without prostatic enlargement 1
• These medications reduce the risk of acute urinary retention and need for surgery 1, 5

Combination Therapy

• Combination of 5-ARI plus alpha blocker should only be offered to patients with demonstrable prostatic enlargement 2
• Combination therapy provides additional benefits for disease progression compared to monotherapy 2

Alternative: Phosphodiesterase-5 Inhibitor

• Tadalafil 5 mg daily produces modest improvement (mean change of -1.74 points in symptom score) and can be considered, particularly if erectile dysfunction is present 2

Why Supplements Are Not Recommended

• Major urological guidelines (AUA, EAU) do not include herbal supplements or phytotherapy in their treatment algorithms 1, 2
• The 2003 AUA guideline noted that available studies on supplements had "inappropriate dosages or nonstandardized outcome measures" 1
• Prescription medications have proven efficacy in preventing disease progression, acute urinary retention, and need for surgery—outcomes not demonstrated with supplements 1, 5

Treatment Algorithm

For moderate to severe BPH symptoms:

• Start with alpha blocker monotherapy for most patients 2
• Consider 5-ARI monotherapy if prostate is enlarged (>30cc, PSA >1.5, or palpable enlargement) 2
• Consider tadalafil 5 mg daily if erectile dysfunction is also present 2

For inadequate response to alpha blocker:

• Add 5-ARI if prostate is enlarged 2
• Consider adding anticholinergic or beta-3-agonist if storage symptoms (urgency, frequency) predominate 2

Critical Caveats

• Do not use 5-ARIs in patients without prostatic enlargement—they are ineffective in this population 1, 2
• Inform patients about sexual side effects of 5-ARIs (decreased libido, ejaculatory dysfunction, erectile dysfunction) 1, 2
• Warn patients planning cataract surgery about intraoperative floppy iris syndrome (IFIS) associated with alpha blockers 1, 4, 2
• Alpha blockers should not be assumed to optimally manage concomitant hypertension in men with cardiac risk factors 1, 4
• Do not combine tadalafil with alpha blockers—provides no additional benefit but increases side effect risk 2