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

Management of BPH with Concurrent Erectile Dysfunction

In patients with BPH who also have erectile dysfunction, initiate treatment with a PDE5 inhibitor (specifically tadalafil 5 mg once daily) as first-line monotherapy, which addresses both conditions simultaneously. 1

Initial Treatment Strategy

PDE5 Inhibitor as Primary Therapy

• Start with tadalafil 5 mg once daily for patients presenting with both BPH/LUTS and ED, taken at approximately the same time each day without regard to timing of sexual activity 2
• This approach is explicitly recommended in the 2021 AUA guideline algorithm, which states: "If patient also has ED, can start with PDE5s as initial therapy" 1
• Tadalafil is FDA-approved specifically for the combined indication of ED/BPH, making it the only medication with dual regulatory approval for both conditions 2
• This strategy optimizes quality of life by addressing sexual function while simultaneously treating urinary symptoms 1

Advantages of PDE5 Inhibitor First-Line Approach

• Preserves sexual function rather than potentially compromising it with other BPH medications 3
• Alpha-blockers and 5-alpha reductase inhibitors commonly cause retrograde ejaculation, ED, and reduced libido 3
• PDE5 inhibitors may have beneficial effects on BPH symptoms beyond just treating ED 3
• Avoids the sexual side effects that would occur with alternative first-line agents 3

When to Add or Switch Therapy

Adding a 5-Alpha Reductase Inhibitor

• If prostate volume exceeds 30 grams, consider adding a 5-ARI (finasteride or dutasteride) to the PDE5 inhibitor regimen 1
• When combining tadalafil with finasteride for BPH initiation, use tadalafil 5 mg once daily for up to 26 weeks, as the incremental benefit of tadalafil decreases from 4 to 26 weeks and is unknown beyond that timeframe 2
• This combination addresses both the static component (prostate size) and improves symptoms while maintaining erectile function 4, 5

Considering Alpha-Blockers

• Alpha-blockers should NOT be combined with tadalafil for BPH treatment due to potential hypotensive effects 2
• If an alpha-blocker is necessary for ED patients, they must be stable on alpha-blocker therapy before initiating tadalafil, and tadalafil should start at the lowest dose 2
• Alpha-blockers work quickly (3-5 days) but carry risks of retrograde ejaculation and sexual dysfunction 5, 3

Critical Dosing Considerations

Renal Impairment Adjustments

• Creatinine clearance 30-50 mL/min: Start tadalafil at 2.5 mg once daily for ED/BPH, may increase to 5 mg based on response 2
• Creatinine clearance <30 mL/min or hemodialysis: Tadalafil once daily is NOT recommended 2

Hepatic Impairment

• Mild to moderate hepatic impairment (Child-Pugh A or B): Use caution with once-daily tadalafil as it has not been extensively evaluated 2
• Severe hepatic impairment (Child-Pugh C): Tadalafil is NOT recommended 2

Drug Interactions

• Potent CYP3A4 inhibitors (ketoconazole, ritonavir): Maximum tadalafil dose is 2.5 mg once daily 2
• Nitrates: Absolute contraindication to tadalafil use 2

Follow-Up and Reassessment

Timing of Evaluation

• Reassess at 4-12 weeks after initiating PDE5 inhibitor therapy (provided no adverse events require earlier consultation) 1
• Use the International Prostate Symptom Score (IPSS) to objectively measure response 1
• Consider post-void residual (PVR) and uroflowmetry for additional objective assessment 1

If Inadequate Response

• Patients without symptom improvement or experiencing intolerable side effects should undergo further evaluation and consideration of changing medical management or surgical intervention 1
• Lack of response may indicate need for combination therapy with 5-ARI (if prostate >30g) or consideration of procedural options 1

Common Pitfalls to Avoid

• Do NOT combine alpha-blockers with tadalafil for BPH treatment—this is explicitly not recommended due to hypotensive risks 2
• Do NOT use 5-ARIs as first-line in ED patients, as they can cause ED and reduced libido, worsening the sexual dysfunction 3
• Do NOT split tadalafil tablets—the entire dose must be taken 2
• Do NOT overlook prostate size assessment—prostates >30g benefit from adding 5-ARI to optimize long-term outcomes 1