Treatment of Dysuria Caused by BPH
Alpha-blockers are the first-line medical therapy for dysuria and other bothersome lower urinary tract symptoms caused by BPH, providing superior and faster symptom relief compared to other medical options. 1, 2
First-Line Treatment: Alpha-Blocker Monotherapy
Start with an alpha-blocker as initial medical therapy for patients with bothersome moderate to severe BPH symptoms (AUA Symptom Score >8), as these agents provide 4-6 point improvement in symptom scores with rapid onset of action. 2
Alpha-Blocker Selection
Choose from the following equally effective agents, but tailor selection based on side effect profile: 3, 2
Tamsulosin 0.4 mg once daily (after the same meal each day) - Lower risk of orthostatic hypotension but higher risk of ejaculatory dysfunction 3, 4
Alfuzosin - Intermediate side effect profile between tamsulosin and doxazosin/terazosin 2, 5
- Take with food and same meal each day; do not crush or chew 5
Terazosin or Doxazosin - Require dose titration, higher risk of orthostatic hypotension and dizziness 3, 2
Expected Outcomes with Alpha-Blockers
- Symptom improvement of 4-6 points on AUA Symptom Index 2
- Peak urine flow improvement of 1-4.3 mL/sec 6
- Symptom relief occurs regardless of prostate size, symptom severity, or degree of obstruction 6
- Works faster than 5-alpha-reductase inhibitors (weeks vs. months) 2
Second-Line and Combination Options
5-Alpha-Reductase Inhibitor (5-ARI) Monotherapy
Reserve 5-ARI monotherapy for patients with documented prostate enlargement who cannot tolerate alpha-blockers or prefer to reduce long-term progression risk. 1, 2
- Finasteride 5 mg daily or dutasteride are options 2, 7
- Less effective than alpha-blockers for symptom relief (3-point vs. 4-6 point improvement) 1, 2
- Requires 6 months to assess effectiveness 2
- Do not use in men without prostatic enlargement - they are ineffective in this population 1
- Side effects include sexual dysfunction and decreased PSA by ~50% 2
Combination Therapy (Alpha-Blocker + 5-ARI)
Consider combination therapy to reduce risk of symptomatic BPH progression and further reduce urinary retention and surgery risk beyond monotherapy. 1, 2
- Best-studied combination: doxazosin plus finasteride 1, 2, 7
- MTOPS and CombAT trials showed statistically significant reductions in clinical progression with combination therapy 1
- Important caveat: Additive adverse effects including asthenia, postural hypotension, peripheral edema, dizziness, and sexual dysfunction 2
Anticholinergics for Storage Symptoms
If dysuria is accompanied by predominant storage symptoms (urgency, frequency), consider adding an anticholinergic to alpha-blocker therapy after starting with alpha-blocker monotherapy. 1
- Start with alpha-blocker alone, then add anticholinergic in selected cases due to variable efficacy and increased adverse events 1
- Obtain post-void residual (PVR) pre-treatment and monitor at follow-up 1
- Tolterodine combined with alpha-blockers can effectively relieve dysuria, frequency, and urgency without significantly affecting flow rate or increasing urinary retention risk 8
Medications to Avoid
Do not combine low-dose daily tadalafil (5 mg) with alpha-blockers - this combination offers no advantages in symptom improvement over either agent alone and increases side effect risk. 1
Follow-Up and Monitoring
- Monitor treatment response using IPSS scores and patient-reported improvement 2
- Continue therapy if patient reports improvement; reassess and discuss alternatives if neutral or worsening response despite stable IPSS 2
- For patients on 5-ARIs, remember PSA is reduced by approximately 50% - adjust interpretation accordingly 2