What is the initial treatment for a patient with Benign Prostatic Hyperplasia (BPH) and Lower Urinary Tract Symptoms (LUTS)?

Initial Treatment for BPH with LUTS

Alpha-blockers are the first-line medical therapy for patients with BPH and LUTS, with alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin all being appropriate options that provide rapid symptom relief within 4 weeks. 1

Treatment Algorithm

Step 1: Initial Evaluation

Before initiating therapy, obtain: 1

• Medical history and physical examination including digital rectal exam (DRE) to assess prostate size
• International Prostate Symptom Score (IPSS) to quantify symptom severity
• Urinalysis to rule out infection or hematuria
• Consider measuring prostate volume (via imaging or PSA) to guide therapy selection

Step 2: First-Line Therapy Selection

For most patients: Start with alpha-blocker monotherapy 1, 2

• All five alpha-blockers produce similar symptom improvement (4-7 point IPSS reduction vs 2-4 points with placebo) 1
• Symptom relief occurs rapidly, typically within 4 weeks 1
• Choice depends on patient-specific factors:

Tamsulosin or alfuzosin are preferred for: 1, 3

• Elderly patients (less blood pressure effect) 4, 5
• Patients with cardiovascular comorbidities
• Patients requiring immediate full-dose therapy (no titration needed) 3, 5

Doxazosin or terazosin require: 1

• Dose titration to minimize first-dose hypotension
• More monitoring for blood pressure effects
• Caution: Doxazosin monotherapy associated with higher congestive heart failure incidence in hypertensive patients 3

Silodosin considerations: 1

• Higher rate of ejaculatory dysfunction compared to other alpha-blockers
• May be avoided in sexually active men concerned about this side effect

Step 3: Consider 5-Alpha Reductase Inhibitor (5-ARI) Addition or Monotherapy

Add 5-ARI (finasteride or dutasteride) if prostate is enlarged: 1, 2

• Prostate volume >30cc on imaging, OR
• PSA >1.5 ng/mL, OR
• Palpable prostate enlargement on DRE

5-ARIs provide: 1, 6

• Prevention of disease progression
• Reduction in acute urinary retention risk (from 6.6% to 2.8% over 4 years) 6
• Reduction in need for future surgery (from 10.1% to 4.6% over 4 years) 6
• However: Slower onset of action (3-6 months for full effect) 1

Critical counseling points for 5-ARIs: 1, 6

• Sexual side effects common: decreased libido (6.4%), impotence (8.1%), decreased ejaculate volume (3.7%) 6
• PSA values must be doubled when monitoring for prostate cancer 1
• Risk of delayed prostate cancer diagnosis if PSA not properly adjusted 1

Step 4: Alternative or Adjunctive Options

Tadalafil 5mg daily may be considered for: 1, 2

• Patients with concomitant erectile dysfunction
• Modest IPSS improvement (-1.74 points vs placebo) 1
• Do not combine with alpha-blockers (no additional benefit, increased side effects) 1, 2

Combination alpha-blocker + 5-ARI for: 1, 2

• Patients with enlarged prostates (>30cc) who need maximal symptom control
• Patients at high risk for progression
• Provides greater reduction in clinical progression than monotherapy 1

Follow-Up Strategy

First follow-up visit timing: 1

• 4 weeks for alpha-blockers (rapid onset agents)
• 3-6 months for 5-ARIs (slower onset)

Assess at follow-up: 1

• IPSS score change
• Adverse medication effects
• Quality of life assessment
• Post-void residual (when available)

If inadequate response or intolerable side effects: 1

• Consider adding 5-ARI if prostate enlarged and not already prescribed
• Consider adding anticholinergic or beta-3 agonist if storage symptoms predominate 1
• Refer to urology for additional workup (urodynamics, cystoscopy) and consideration of surgical options 1

Critical Pitfalls to Avoid

Cataract surgery: 1

• Always ask about planned cataract surgery before starting alpha-blockers
• Alpha-blockers increase risk of intraoperative floppy iris syndrome (IFIS)
• Delay alpha-blocker initiation until after cataract surgery if planned
• Inform ophthalmologist if patient already on alpha-blocker 2

5-ARI prescribing errors: 1, 2

• Do not prescribe 5-ARIs for small prostates (ineffective) 1
• Always counsel about sexual side effects before initiation 1
• Remember to double PSA values for cancer screening 1

Combination therapy mistakes: 1, 2

• Do not combine tadalafil with alpha-blockers (no benefit, more side effects)
• Only combine alpha-blocker + 5-ARI when prostate is demonstrably enlarged 1