What is the first line of treatment for Benign Prostatic Hyperplasia (BPH)?

First-Line Treatment for Benign Prostatic Hyperplasia

Alpha-blockers are the first-line medical therapy for patients with bothersome moderate to severe BPH symptoms (AUA Symptom Score >8), providing superior symptom relief (4-6 point improvement) with faster onset of action compared to other medical options. 1

When to Treat vs. Observe

• Watchful waiting is appropriate for patients with mild symptoms or those with moderate-to-severe symptoms who are not sufficiently bothered to pursue active treatment 1, 2
• Patients on watchful waiting should be monitored yearly with repeat evaluations and implement lifestyle modifications including reduced evening fluid intake, limited caffeine and alcohol consumption 1, 2
• Medical therapy should be initiated when AUA Symptom Score >8 with bothersome symptoms 1

Alpha-Blocker Selection and Efficacy

All available alpha-blockers are similarly effective (producing 4-6 point IPSS improvement), but differ in their adverse effect profiles 1:

• Tamsulosin and silodosin: Lower risk of orthostatic hypotension but higher risk of ejaculatory dysfunction 1, 2
• Doxazosin and terazosin: Require dose titration and carry higher risk of orthostatic hypotension and dizziness 1
• Alfuzosin: Intermediate adverse effect profile 1

Clinical response occurs rapidly, typically within 2-4 weeks, allowing for quick assessment of treatment success 3, 4

Critical Caveats for Alpha-Blockers

• Patients planning cataract surgery should be informed about intraoperative floppy iris syndrome (IFIS) risk; consider delaying alpha-blocker initiation until after surgery 1
• In men with hypertension and cardiac risk factors, alpha-blockers should not be assumed to constitute optimal hypertension management and may require separate antihypertensive therapy 1, 5
• First-dose effect warning: Alpha-blockers can cause sudden drop in blood pressure, particularly after the first dose, causing dizziness or lightheadedness; consider bedtime dosing 4

5-Alpha-Reductase Inhibitors as Alternative First-Line

5-ARIs (finasteride 5 mg daily or dutasteride) are appropriate first-line therapy specifically for patients with documented prostatic enlargement 3, 1, 6, 7:

• Less effective than alpha-blockers for symptom improvement (3-point vs 4-6 point IPSS improvement) 1
• Require at least 6 months to assess treatment effectiveness 3, 1
• Major advantage: Reduce risk of acute urinary retention and need for BPH-related surgery 1, 6, 7
• Adverse effects: Sexual dysfunction (decreased ejaculation, decreased libido, impotence), decrease PSA by approximately 50%, and potential increased risk of Gleason 8-10 prostate cancer 3, 1

Combination Therapy

Combination therapy (alpha-blocker + 5-ARI) is indicated to reduce risk of symptomatic BPH progression and further reduce risk of urinary retention and surgery beyond either monotherapy 1:

• Best-studied combination is doxazosin plus finasteride 3, 6
• Additive adverse effects include higher incidence of asthenia, postural hypotension, peripheral edema, dizziness, and sexual dysfunction 3, 1
• Appropriate for patients with LUTS associated with demonstrable prostatic enlargement 3

Surgical Referral Indications

Absolute indications for surgical referral include 2, 5:

• Refractory urinary retention
• Renal insufficiency attributable to BPH
• Recurrent urinary tract infections
• Recurrent gross hematuria
• Bladder stones clearly attributable to BPH
• Moderate-to-severe LUTS refractory to medical therapy or intolerable drug-related side effects

TURP remains the benchmark surgical therapy with strongest long-term efficacy data 1, 2