What treatment is recommended for a male with urinary frequency, weak urinary stream, prolonged dribbling, and erectile dysfunction, who is taking hydrochlorothiazide (HCTZ), norvasc (amlodipine), and atorvastatin, with impaired fasting glucose and mildly elevated Blood Urea Nitrogen (BUN) levels?

Treatment Recommendation for BPH with Erectile Dysfunction

This patient should be started on combination therapy with an alpha-blocker (tamsulosin or similar) plus a 5-alpha reductase inhibitor (finasteride or dutasteride), and tadalafil 5mg daily should be added to address both lower urinary tract symptoms and erectile dysfunction. 1

Clinical Presentation Analysis

This patient presents with classic benign prostatic hyperplasia (BPH) symptoms:

• Voiding symptoms: weak stream, prolonged dribbling, urinary frequency 1
• Sexual dysfunction: erectile dysfunction, which commonly coexists with BPH 1
• Risk factors: The impaired fasting glucose (125 mg/dL) and mildly elevated BUN (22) suggest metabolic syndrome and possible early renal changes, both associated with BPH progression 2

Primary Treatment: Combination Therapy for BPH

Alpha-Blocker Foundation

• Continue or initiate an alpha-blocker (tamsulosin 0.4mg daily is preferred given his hypertension, as it has lower risk of orthostatic hypotension compared to other alpha-blockers) 3
• Alpha-blockers provide rapid symptom relief within weeks by relaxing prostatic smooth muscle 4
• Critical caveat: Alpha-blockers used for LUTS should NOT be assumed to provide optimal management of his hypertension; his blood pressure requires separate evaluation and management 3

Add 5-Alpha Reductase Inhibitor

• Add finasteride 5mg daily or dutasteride 0.5mg daily to the alpha-blocker 1, 5
• This combination is strongly recommended for patients with demonstrable prostatic enlargement (suggested by his symptoms and likely PSA >1.5 ng/mL or prostate volume >30cc on exam) 1
• Rationale: Combination therapy provides:
  • 67% reduction in overall BPH clinical progression 5
  • 79% reduction in acute urinary retention risk 5
  • 67% reduction in need for BPH-related surgery 5
  • Greater and more durable symptom improvement than monotherapy 6

Timeline Expectations

• Alpha-blocker effects: Symptom improvement within 2-4 weeks 4
• 5-ARI effects: Requires 3-6 months for clinical benefit; prostate volume reduction of 15-25% after 6 months 5
• Follow-up: Schedule reassessment at 3 months to evaluate combination therapy efficacy 2

Addressing Erectile Dysfunction: Add Tadalafil

Add tadalafil 5mg daily to the combination therapy above 1

Evidence for Tadalafil in BPH with ED

• Tadalafil 5mg daily is the only PDE5 inhibitor approved for LUTS treatment 3
• Provides dual benefit: improves both LUTS (mean IPSS improvement of -1.74 points vs placebo) and erectile function 1
• Particularly appropriate for this patient who has both LUTS and erectile dysfunction 1
• When combined with alpha-blockers, provides additional improvement in IPSS score (-1.8), erectile function (+3.6), and maximum flow rate (+1.5 ml/s) 3

Important Limitation

• Do NOT combine tadalafil with alpha-blockers if the goal is LUTS improvement alone, as this offers no advantages over either agent alone 1
• However, in this patient with BOTH LUTS and ED, tadalafil is justified for the erectile dysfunction indication while potentially providing modest additional LUTS benefit 1

Critical Safety Considerations

PSA Monitoring

• 5-ARIs reduce PSA by approximately 50% after 1 year 5
• For prostate cancer screening: double the measured PSA value after 1 year of 5-ARI therapy for accurate interpretation 5
• Failure to adjust PSA values can lead to delayed cancer diagnosis and worse outcomes 1

Sexual Side Effects of 5-ARIs

• Erectile dysfunction: 4-15% of patients 5
• Decreased libido: 6.4% in first year 5
• Ejaculatory dysfunction: 3.7% in first year 5
• These effects typically decrease after the first year but may persist in some patients 5
• Counsel patient: The addition of tadalafil may help mitigate some erectile dysfunction from the 5-ARI 1

Cardiovascular Considerations

• Tamsulosin is associated with intraoperative floppy iris syndrome during cataract surgery; patient must inform ophthalmologists before any eye surgery 5
• Monitor blood pressure separately; do not assume tamsulosin adequately treats his hypertension 3

Alternative Considerations if Initial Therapy Fails

If symptoms persist after 3-6 months of optimized combination therapy:

• Consider adding a beta-3 agonist (mirabegron) if storage symptoms (frequency, urgency) predominate 1, 5
• Consider adding an anticholinergic for predominant storage symptoms, though use cautiously given potential to worsen voiding symptoms and increase post-void residual 1, 2
• Urologic referral for consideration of surgical options if medical therapy fails 2

Management of Comorbidities

Impaired Fasting Glucose (125 mg/dL)

• Address prediabetes/diabetes risk, as metabolic syndrome is associated with BPH progression 2
• Lifestyle modifications and possible metformin initiation should be considered

Mildly Elevated BUN (22)

• Monitor renal function, as BPH can lead to obstructive uropathy 2
• Combination therapy reduces risk of urinary retention and subsequent renal complications 5

Hypertension Management

• His current regimen (hydrochlorothiazide, amlodipine) should be optimized independently of BPH treatment 3
• Do not rely on tamsulosin for blood pressure control 3