What is the initial treatment for benign prostatic hyperplasia (BPH) or prostatism?

Initial Treatment for Benign Prostatic Hyperplasia (BPH)

Alpha blockers are the first-line medical treatment for BPH, providing rapid symptom relief within days to weeks, with tamsulosin or alfuzosin preferred as they require no dose titration and can be started immediately at therapeutic doses. 1

First-Line Treatment: Alpha Blockers

Start with an alpha blocker for most patients with moderate to severe lower urinary tract symptoms (LUTS) from BPH. 1 The American Urological Association recommends five alpha blockers as treatment options: alfuzosin, doxazosin, silodosin, tamsulosin, and terazosin. 1

Mechanism and Efficacy

• Alpha blockers work by inhibiting alpha1-adrenergic-mediated contraction of prostatic smooth muscle, relieving bladder outlet obstruction. 1, 2
• All five alpha blockers have similar clinical effectiveness, producing on average a 4-7 point improvement in International Prostate Symptom Score (IPSS) compared to 2-4 points with placebo. 1
• Symptom improvement begins within 3-5 days of starting therapy. 3

Preferred Alpha Blockers

Tamsulosin 0.4 mg once daily or alfuzosin 10 mg extended-release once daily are the preferred choices because:

• They do not require dose titration and can be started immediately at therapeutic doses. 4
• Tamsulosin has less effect on blood pressure compared to other alpha blockers, making it safer for elderly patients and those with cardiovascular concerns. 4, 5
• Both medications allow once-daily dosing, improving adherence. 6

Choice Between Alpha Blockers Based on Side Effect Profile

• Tamsulosin has a lower probability of orthostatic hypotension but a higher probability of ejaculatory dysfunction compared to other alpha blockers. 7, 2
• Terazosin and doxazosin require dose titration and have higher rates of orthostatic hypotension, dizziness, and fatigue. 2, 6
• Alfuzosin has more hypotensive side effects than tamsulosin but less ejaculatory dysfunction. 6
• The choice should be based on patient age, comorbidities, and different adverse event profiles. 1, 2

Critical Warnings

• Patients planning cataract surgery must be informed about the risk of intraoperative floppy iris syndrome (IFIS) associated with all alpha blockers. 1, 2
• In men with hypertension and cardiac risk factors, doxazosin monotherapy was associated with higher incidence of congestive heart failure; alpha blocker use for LUTS should not be assumed to constitute optimal management of concomitant hypertension. 7, 2

Second-Line or Alternative Treatment: 5-Alpha Reductase Inhibitors (5-ARIs)

5-ARIs (finasteride or dutasteride) should be used as monotherapy only in men with demonstrable prostatic enlargement (prostate volume >30cc, PSA >1.5ng/mL, or palpable enlargement). 1

When to Use 5-ARIs

• 5-ARIs are appropriate for patients with LUTS associated with demonstrable prostatic enlargement. 7
• 5-ARIs are NOT appropriate for men with LUTS who do not have evidence of prostatic enlargement. 7
• Finasteride is less effective than an alpha blocker in improving LUTS. 7

Mechanism and Efficacy

• 5-ARIs work by blocking the conversion of testosterone to dihydrotestosterone, leading to prostate volume reduction. 1
• Finasteride produces an average 3-point improvement in symptom score, which patients generally perceive as meaningful change. 7
• 5-ARIs reduce the risk of acute urinary retention and the need for BPH-related surgery. 7, 8
• Symptom improvement requires at least 6 months to assess beneficial response. 8

FDA-Approved Indications for Finasteride

• Improve symptoms in men with enlarged prostate. 8
• Reduce the risk of acute urinary retention. 8
• Reduce the risk of need for surgery including TURP and prostatectomy. 8

Side Effects

• Sexual side effects are common, including decreased libido, ejaculatory dysfunction, and erectile dysfunction. 7, 1
• These adverse events are reversible and uncommon after the first year of therapy. 7
• Finasteride lowers serum PSA by approximately 50%, but does not mask PSA-based detection of prostate cancer. 7

Combination Therapy

Combination therapy with alpha blocker plus 5-ARI should be offered only to patients with demonstrable prostatic enlargement (prostate volume >30cc, PSA >1.5ng/mL, or palpable enlargement). 1

• Finasteride administered in combination with doxazosin is FDA-approved to reduce the risk of symptomatic progression of BPH. 8
• Two large studies (MTOPS and CombAT) showed statistically significant reductions in clinical progression with combination therapy over monotherapy. 1
• If symptoms persist despite adequate trial of alpha blocker monotherapy, consider adding a 5-ARI if the prostate is enlarged. 4

Alternative Option: Tadalafil

For patients with LUTS/BPH, regardless of erectile dysfunction status, tadalafil 5mg daily should be discussed as a treatment option, particularly if erectile dysfunction is present. 1

• Tadalafil produces a modest improvement in IPSS compared to placebo, with a mean change of -1.74 points. 1
• Do not combine tadalafil with alpha blockers, as this provides no additional benefit but increases side effect risk. 4

Treatment Algorithm Summary

For Initial Treatment of Moderate to Severe LUTS/BPH:

1. Start with alpha blocker monotherapy (tamsulosin 0.4 mg or alfuzosin 10 mg once daily) for most patients. 1, 4
2. Consider 5-ARI monotherapy (finasteride 5 mg or dutasteride) if prostate is enlarged. 1
3. Consider tadalafil 5mg daily, particularly if erectile dysfunction is present. 1

For Inadequate Response to Alpha Blocker Monotherapy:

1. Add 5-ARI if prostate is enlarged. 1
2. Consider adding anticholinergic agent if storage symptoms predominate. 1
3. Consider adding beta-3-agonist if storage symptoms predominate. 1

Common Pitfalls to Avoid

• Failing to assess prostate size before initiating 5-ARI therapy, as 5-ARIs are only effective for enlarged prostates. 1
• Not informing patients about sexual side effects of 5-ARIs. 1
• Combining tadalafil with alpha blockers, which provides no additional benefit but increases side effect risk. 4
• Not informing ophthalmologists about alpha blocker use before cataract surgery. 1
• Using doxazosin or terazosin without proper dose titration, which increases risk of first-dose hypotensive effects and syncope. 4
• Delaying treatment waiting for symptoms to worsen, as early intervention with alpha blockers can significantly improve quality of life. 4

Special Consideration: Acute Urinary Retention

For patients with acute urinary retention (AUR) related to BPH, prescribe an oral alpha blocker (alfuzosin or tamsulosin) for at least three days before attempting a trial without catheter (TWOC). 1