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

BPH Medication Options

For patients with bothersome moderate to severe BPH symptoms (AUA Symptom Score >8), first-line medical therapy consists of alpha-adrenergic blockers (alfuzosin, doxazosin, tamsulosin, or terazosin) or 5-alpha reductase inhibitors (finasteride or dutasteride), with combination therapy reserved for men with enlarged prostates at risk of disease progression. 1, 2, 3

Treatment Algorithm Based on Symptom Severity

Mild Symptoms (AUA Score <7) or Non-Bothersome Symptoms

• Watchful waiting is the standard approach for patients whose symptoms do not interfere with daily activities 1
• Monitor yearly with repeat symptom assessments 4
• Implement lifestyle modifications: reduce fluid intake at bedtime, decrease caffeine and alcohol consumption 4

Moderate to Severe Bothersome Symptoms (AUA Score >8)

Alpha-Adrenergic Blockers (First-Line)

Alpha-blockers provide rapid symptom relief within 2-4 weeks by relaxing prostatic smooth muscle and relieving bladder outlet obstruction. 1, 4, 5

Specific Agents:

• Alfuzosin, doxazosin, tamsulosin, and terazosin are all appropriate options 1
• These agents produce an average 4-6 point improvement in AUA Symptom Index that patients perceive as meaningful 4

Key Differences Between Alpha-Blockers:

• Tamsulosin has lower risk of orthostatic hypotension but higher risk of ejaculatory dysfunction 4
• Alfuzosin requires no dose titration and is taken once daily with food 6
• Doxazosin and terazosin require dose titration but can treat concurrent hypertension 7
• Monitor for first-dose orthostatic hypotension, particularly in elderly patients 4, 6

Critical Caveat:

• Patients planning cataract surgery must inform their ophthalmologist about alpha-blocker use due to intraoperative floppy iris syndrome risk 6

5-Alpha Reductase Inhibitors

5-ARIs are most effective in men with enlarged prostates (>40ml volume or elevated PSA as proxy) and require 6-12 months for maximum benefit. 2, 3, 7

Available Agents:

• Finasteride is indicated for symptomatic BPH to improve symptoms, reduce risk of acute urinary retention, and reduce need for surgery 2
• Dutasteride has identical indications as finasteride 3

Advantages of 5-ARIs:

• Reduce prostate volume over time 1
• Decrease risk of disease progression and need for surgery 2, 3
• May reduce prostatic bleeding 1

Limitations:

• Require at least 6 months before effectiveness can be assessed 7
• Should not be used in men with prostate volume <40ml 7
• Not approved for prostate cancer prevention 2, 3

Combination Therapy

Finasteride combined with doxazosin is indicated to reduce risk of symptomatic BPH progression (≥4 point increase in AUA score). 1, 2

Dutasteride combined with tamsulosin is indicated for treatment of symptomatic BPH in men with enlarged prostates. 3

When to Consider Combination:

• Men with larger prostates (>40ml) at higher risk of progression 1
• Patients requiring both immediate symptom relief (alpha-blocker) and long-term disease modification (5-ARI) 1

Important Warning:

• Combination therapy may increase adverse effects including asthenia and postural hypotension 4
• The safety of combinations other than finasteride plus doxazosin, terazosin, or alfuzosin has not been fully assessed 1

Clinical Decision Points

Prostate Size Matters:

• Serum PSA serves as proxy for prostate volume and predicts response to 5-ARI therapy 1
• Alpha-blockers work regardless of prostate size 1
• 5-ARIs only effective when prostate volume >40ml 7

When Medical Therapy Fails:

• Surgery remains the benchmark therapy for patients with moderate-to-severe LUTS who fail medical management 4
• TURP provides the most robust long-term efficacy data 4

Absolute Indications for Surgery (Not Medical Therapy)

Surgery is recommended for patients with: 1

• Refractory urinary retention after failed catheter removal
• Renal insufficiency clearly due to BPH
• Recurrent UTIs due to BPH
• Recurrent gross hematuria due to BPH
• Bladder stones due to BPH

Optional Pre-Catheter Removal Strategy:

• Consider administering non-titratable alpha-blocker (tamsulosin or alfuzosin) prior to trial of catheter removal in retention patients 1

Contraindications and Precautions

Alpha-Blockers:

• Alfuzosin is contraindicated in patients with liver problems or those taking ketoconazole or HIV protease inhibitors 6
• Avoid in patients with history of severe orthostatic hypotension 6

5-ARIs:

• Not approved for prostate cancer prevention despite reducing PSA levels 2, 3
• May cause sexual dysfunction including decreased libido and erectile dysfunction 5