What are the alternative treatments for Benign Prostatic Hyperplasia (BPH)?

From the Guidelines

Alternative treatments for benign prostatic hyperplasia (BPH) should prioritize watchful waiting for patients with mild symptoms or moderate to severe symptoms without bother, as the risks of medical therapy outweigh the benefits of symptom improvement in this group of men. The American Urological Association (AUA) guideline on management of BPH recommends watchful waiting for patients with mild symptoms of BPH (AUA Symptom Score <7) and patients with moderate or severe symptoms (AUA Symptom Score >8) who are not bothered by their symptoms 1. For patients with bothersome moderate to severe symptoms, treatment options include medical therapies, such as alpha-adrenergic blockers and 5 alpha-reductase inhibitors, minimally invasive therapies, such as transurethral microwave heat treatments and transurethral needle ablation, and surgical therapies, such as transurethral resection of the prostate and transurethral holmium laser resection/enucleation 1. Some key points to consider when evaluating treatment options for BPH include:

• The degree to which BPH patients are bothered by lower urinary tract symptoms (LUTS) varies among individual patients with the same level of symptoms
• Patients may prefer less effective therapy if it also has less risk or cost
• The benefits and harms of all therapeutic interventions should be discussed with the patient using the Simplified Outcomes Tables
• Optional diagnostic tests, such as pressure-flow urodynamic studies, urethrocystoscopy, and ultrasound, may be valuable in predicting the response to therapy in specific circumstances
• Lifestyle modifications, such as reducing fluid intake before bedtime, limiting caffeine and alcohol consumption, and practicing double voiding, may also be beneficial in managing BPH symptoms. Ultimately, the choice of treatment should be based on a discussion between the patient and healthcare provider, taking into account the patient's individual preferences, symptoms, and medical history.

From the FDA Drug Label

The efficacy and safety of tadalafil for once daily use for the treatment of the signs and symptoms of BPH was evaluated in 3 randomized, multinational, double-blinded, placebo-controlled, parallel-design, efficacy and safety studies of 12 weeks duration Two of these studies were in men with BPH and one study was specific to men with both ED and BPH The primary efficacy endpoint in the two studies that evaluated the effect of tadalafil for the signs and symptoms of BPH was the International Prostate Symptom Score (IPSS), a four week recall questionnaire that was administered at the beginning and end of a placebo run-in period and subsequently at follow-up visits after randomization In each of these 2 trials, tadalafil 5 mg for once daily use resulted in statistically significant improvement in the total IPSS compared to placebo

Alternative treatments for BPH include:

• Tadalafil 5 mg once daily, which has been shown to improve the signs and symptoms of BPH, as measured by the International Prostate Symptom Score (IPSS) 2
• Finasteride, which can be used in combination with tadalafil for up to 26 weeks to initiate BPH treatment 2 Note that the FDA label does not provide a comprehensive list of alternative treatments for BPH, and other options may be available.

From the Research

Alternative Treatments for BPH

• Tadalafil, a phosphodiesterase-5 inhibitor, has been approved for the treatment of lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) 3, 4.
• The mechanism of action of tadalafil in improving LUTS is thought to be related to alterations in nitric oxide levels, Rho-associated protein kinase deactivation, and reductions in pelvic atherosclerosis 3.
• Other phosphodiesterase-5 inhibitors, such as udenafil, have also shown positive results in treating BPH and LUTS, although their efficacy compared to tadalafil is not well established 5.
• Medical therapy, including alpha-blockers, muscarinic receptor antagonists, 5-alpha-reductase inhibitors, and combination therapies, is a cornerstone of treatment for BPH, with a need for personalized approaches to meet individual patient needs and preferences 6.
• Treatment satisfaction among men with concurrent BPH and erectile dysfunction (ED) is higher with tadalafil monotherapy compared to other phosphodiesterase type-5 inhibitor combinations, with greater reported ease of treatment planning and convenience 7.

Phosphodiesterase-5 Inhibitors for BPH

• Tadalafil and other phosphodiesterase-5 inhibitors have been shown to increase cAMP and cGMP levels in prostate tissues and plasma, which may contribute to their therapeutic effects in BPH 5.
• The distribution of phosphodiesterase-5 inhibitors in prostate tissue and plasma varies, with udenafil having a higher tissue-to-plasma ratio compared to tadalafil 5.
• The use of phosphodiesterase-5 inhibitors, such as tadalafil, may be beneficial for men with concurrent BPH and ED, offering a convenient and effective treatment option for both conditions 3, 7.

Medical Therapy for BPH

• A range of medical therapies are available for the treatment of BPH, including phytotherapy, alpha-blockers, muscarinic receptor antagonists, 5-alpha-reductase inhibitors, and combination therapies 6.
• The choice of medical therapy for BPH should be tailored to individual patient needs and preferences, taking into account factors such as symptom severity, comorbidities, and treatment goals 6.
• Further research is needed to fully understand the efficacy and safety of different medical therapies for BPH, as well as to develop personalized treatment approaches that meet the unique needs of each patient 6.