How to manage Benign Prostatic Hyperplasia (BPH) and Erectile Dysfunction (ED) simultaneously?

Managing BPH and Erectile Dysfunction Simultaneously

Tadalafil 5 mg once daily is the optimal single-agent therapy for men with both BPH and ED, as it effectively treats both conditions simultaneously without the sexual side effects associated with other BPH medications. 1

First-Line Treatment Strategy

Tadalafil as Monotherapy

• Tadalafil 5 mg once daily should be the initial treatment for men presenting with both BPH/LUTS and ED, as it significantly improves both urinary symptoms (mean IPSS reduction of -6.0 points vs -3.6 for placebo) and erectile function (IIEF-EF improvement of 6.4 vs 1.4 for placebo) 2
• This approach addresses both conditions with a single medication, improving treatment adherence and avoiding the sexual dysfunction side effects common with alpha-blockers 3
• Approximately 40.5% of men treated with tadalafil 5 mg achieve combined response (improvement in both ED and LUTS/BPH symptoms) compared to only 18.3% with placebo 4
• Tadalafil also improves ejaculatory function and orgasmic frequency, unlike alpha-blockers which can worsen these parameters 3

When Tadalafil Alone is Insufficient

If tadalafil monotherapy provides inadequate LUTS control after 4-12 weeks, add an alpha-blocker to the regimen 1:

• The combination of tadalafil with alpha-blockers offers no additional benefit over either agent alone for LUTS improvement, but this recommendation is based on Grade C evidence 1
• Despite guideline recommendations against combination, clinical practice may warrant sequential addition if monotherapy fails
• When adding an alpha-blocker, choose tamsulosin over other alpha-blockers to minimize orthostatic hypotension risk, though be aware it carries higher risk of ejaculatory dysfunction 5
• Avoid doxazosin in patients with cardiac risk factors due to increased congestive heart failure risk 1, 5

Alternative Sequential Approach

Alpha-Blocker First, Then Address ED Separately

If you choose to start with an alpha-blocker for LUTS:

• Initiate alpha-blocker therapy (tamsulosin, alfuzosin, or silodosin) for rapid LUTS improvement (2-4 weeks) 5, 6
• Treat ED separately with on-demand PDE5 inhibitors (sildenafil, vardenafil, or avanafil) rather than daily tadalafil 1
• This approach separates the management of both conditions but requires multiple medications and may worsen ejaculatory function with the alpha-blocker 3

For Men with Enlarged Prostates (>30cc)

Add a 5-alpha reductase inhibitor (5-ARI) to the regimen only if prostate volume >30cc, PSA >1.5 ng/mL, or palpable enlargement on DRE 1:

• 5-ARIs (finasteride or dutasteride) reduce prostate size by 15-25% over 6 months and prevent disease progression 5, 6
• Critical caveat: 5-ARIs cause sexual dysfunction (decreased libido, erectile dysfunction, ejaculatory dysfunction) in a subset of patients, which may persist even after discontinuation (post-finasteride syndrome) 1
• If using tadalafil with finasteride, limit combination therapy to 26 weeks maximum, as incremental benefit of tadalafil decreases after this period 7
• Always double the PSA value when monitoring for prostate cancer in men taking 5-ARIs, as these medications reduce PSA by approximately 50% 1, 5

Critical Monitoring and Follow-Up

• Evaluate response at 4-12 weeks after initiating tadalafil or alpha-blockers 1, 6
• Reassess using IPSS questionnaire and erectile function assessment 6
• For 5-ARI therapy, first follow-up should be at 3-6 months due to delayed onset of action 6
• Monitor for orthostatic hypotension, especially when combining tadalafil with alpha-blockers or antihypertensive medications 7

Key Contraindications and Drug Interactions

Absolute contraindications to tadalafil 7:

• Concurrent nitrate use (including recreational "poppers")
• Guanylate cyclase stimulators (riociguat)
• Recent stroke or myocardial infarction
• Uncontrolled hypertension or hypotension

Exercise caution when combining tadalafil with alpha-blockers, as this may cause significant hypotension, dizziness, or syncope 7

Common Pitfalls to Avoid

• Do not assume alpha-blockers used for LUTS adequately control hypertension—separate antihypertensive management may be required 1, 5
• Do not use 5-ARIs as first-line therapy without documented prostate enlargement, as they are ineffective in men with normal-sized prostates 1
• Warn patients planning cataract surgery about alpha-blocker use due to intraoperative floppy iris syndrome (IFIS) risk 5
• Do not overlook the need to adjust PSA values (double the value) when screening for prostate cancer in men on 5-ARIs 1, 5