Does Cialis Unmask Prostate Bleeding?
Cialis (tadalafil) does not unmask prostate bleeding and is not contraindicated in patients with benign prostatic hyperplasia (BPH), including those with a history of prostatic bleeding. In fact, tadalafil is FDA-approved for the treatment of BPH symptoms and can be safely used in this population 1, 2.
Evidence Supporting Safety in BPH
The available evidence demonstrates that tadalafil is both safe and effective for treating lower urinary tract symptoms (LUTS) associated with BPH:
Multiple phase III trials have established that tadalafil 5 mg once daily significantly improves International Prostate Symptom Score (IPSS) by 5.6 points compared to 3.6 points with placebo, with no reports of unmasking or worsening prostatic bleeding 3, 4.
Long-term safety data extending up to 1 year show that tadalafil is well-tolerated in BPH patients, with the most common adverse events being headache (3.7%), back pain (3.1%), and dyspepsia—none related to prostatic bleeding 2, 3.
Vascular effects in the prostate have been studied using contrast-enhanced ultrasound, showing that tadalafil increases prostatic blood flow and vascularity, but this hemodynamic change does not translate to clinical bleeding complications 5.
Understanding Prostatic Bleeding in BPH
The concern about "unmasking" bleeding is theoretically based on tadalafil's vasodilatory effects, but this has not materialized as a clinical problem:
Prostatic bleeding is an uncommon complication of BPH itself, and when gross hematuria occurs, it must be proven to be of prostatic etiology through appropriate evaluation 6.
The 2003 AUA guidelines note that recurrent gross hematuria due to BPH is an indication for surgical intervention, but this is independent of medication use and reflects the natural history of severe BPH 6.
5-alpha reductase inhibitors (not PDE-5 inhibitors like tadalafil) are the medication class specifically noted to decrease the probability of prostate bleeding in BPH patients 6.
Clinical Application
For patients with BPH and concurrent erectile dysfunction, tadalafil 5 mg once daily treats both conditions simultaneously and is FDA-approved for this dual indication 1, 2.
For patients with a history of prostatic bleeding, the appropriate workup includes:
- Cystoscopy and upper tract imaging to exclude bladder cancer, stones, or other pathology 6
- Consideration of 5-alpha reductase inhibitor therapy to reduce prostate vascularity and bleeding risk 6
- Tadalafil can still be used safely once other causes of hematuria are excluded 2, 3
Common Pitfalls to Avoid
Do not withhold tadalafil based on theoretical bleeding concerns that lack clinical evidence 2, 3.
Do not confuse tadalafil's hemodynamic effects (increased prostatic blood flow on imaging) with clinical bleeding—these are distinct phenomena 5.
Do not assume tadalafil adequately treats BPH in patients with large prostates (>80cc) or severe symptoms, as these patients may require combination therapy with alpha-blockers or 5-alpha reductase inhibitors, or surgical referral 7, 8.
Always evaluate gross hematuria appropriately regardless of medication use, as it may indicate bladder cancer, stones, or other serious pathology requiring different management 6.