What is the recommended alpha blocker (e.g. Flomax (tamsulosin)) for a male patient over 50 with benign prostatic hyperplasia (BPH)?

Recommended Alpha Blocker for BPH

Tamsulosin (Flomax) 0.4 mg once daily is the recommended alpha blocker for men over 50 with BPH, as it provides meaningful symptom improvement without requiring dose titration and has the lowest risk of orthostatic hypotension among alpha blockers. 1, 2

Why Tamsulosin is the Preferred Choice

• Tamsulosin produces a 4-6 point improvement in the AUA Symptom Index, which patients generally perceive as meaningful symptom relief 1, 3
• The drug works by inhibiting alpha-1A-adrenergic receptors in prostatic smooth muscle, relieving bladder outlet obstruction 4, 5
• No dose titration is required—start at 0.4 mg once daily, taken 30 minutes after the same meal each day 2, 6
• Symptom improvement begins within 3-5 days and is maintained long-term 7, 8

Comparative Advantages Over Other Alpha Blockers

While alfuzosin, doxazosin, terazosin, and silodosin are all equally effective alternatives 9, 1, tamsulosin offers specific advantages:

• Lower probability of orthostatic hypotension compared to doxazosin and terazosin 9, 1
• No first-dose syncope risk, unlike terazosin and doxazosin 8
• Once-daily dosing without titration, unlike doxazosin and terazosin which require gradual dose escalation 6
• Can be safely combined with common antihypertensive medications (nifedipine, enalapril, atenolol, furosemide) without causing hypotension 8

Important Caveats and Side Effects

Common adverse effects to counsel patients about:

• Ejaculatory dysfunction occurs in 4.5-14% of patients (higher than other alpha blockers) 9, 1, 8
• Asthenia (tiredness) and nasal congestion are common 1
• Dizziness and rhinitis may occur 3

Critical safety consideration:

• Patients planning cataract surgery must inform their ophthalmologist about tamsulosin use due to intraoperative floppy iris syndrome (IFIS) risk 1
• Ideally, delay tamsulosin initiation until after cataract surgery 1

Dosing Algorithm

1. Start with tamsulosin 0.4 mg once daily, taken 30 minutes after the same meal 2
2. Reassess at 4 weeks for symptom improvement using IPSS, quality of life assessment, and adverse effects 1
3. If inadequate response after 2-4 weeks, increase to 0.8 mg once daily 2
4. If therapy is interrupted for several days, restart at 0.4 mg (do not resume at 0.8 mg) 2

When to Consider Combination Therapy

Add a 5-alpha reductase inhibitor (finasteride 5 mg or dutasteride 0.5 mg daily) if the patient has:

• Prostate volume >30cc on imaging, OR 1
• PSA >1.5 ng/mL, OR 1
• Palpable prostate enlargement on DRE 1

This combination reduces long-term risk of acute urinary retention by 68% and need for surgery by 71% compared to tamsulosin alone 1

Alternative Alpha Blockers

If tamsulosin is not tolerated or contraindicated:

• Alfuzosin has similar efficacy with potentially lower ejaculatory dysfunction rates 6
• Silodosin is preferred for rapid symptom relief but has the highest rate of ejaculatory dysfunction 1
• Doxazosin and terazosin require dose titration and have higher orthostatic hypotension risk, but may benefit patients needing concurrent hypertension management 9

What Tamsulosin Does NOT Do

• Does not reduce prostate size or volume (unlike 5-alpha reductase inhibitors) 4
• Does not reduce long-term risk of acute urinary retention or surgery when used as monotherapy 1
• Ineffective in patients without a prostate (post-prostatectomy patients should not receive tamsulosin) 10