From the Guidelines
For a male with BPH experiencing urinary issues, I strongly recommend starting with a combination of alpha-blockers and 5-alpha reductase inhibitors, as this approach has been shown to provide significant symptom relief and improve quality of life, as supported by the most recent guideline from 2024 1. The treatment of BPH should prioritize reducing morbidity, mortality, and improving quality of life.
Key Considerations
- The patient's symptoms and medical history should be thoroughly evaluated to determine the best course of treatment.
- Lifestyle modifications, such as limiting fluid intake before bedtime, reducing caffeine and alcohol consumption, and avoiding decongestants and antihistamines, can help manage symptoms.
- Alpha-blockers, such as tamsulosin (Flomax) 0.4 mg daily or alfuzosin 10 mg daily, can provide quick symptom relief by relaxing the smooth muscle in the prostate and bladder neck.
- For more severe symptoms or larger prostates, adding a 5-alpha reductase inhibitor like finasteride 5 mg daily or dutasteride 0.5 mg daily can help reduce prostate size over 3-6 months, as recommended by the AUA guideline from 2003 1.
Treatment Options
- Medications: alpha-blockers, 5-alpha reductase inhibitors, and combination therapy.
- Lifestyle modifications: fluid intake management, dietary changes, and avoidance of exacerbating factors.
- Surgical options: transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate, photovaporization of the prostate, and other minimally invasive procedures, as discussed in the 2024 guideline 1.
Monitoring and Follow-up
- Regular follow-up is essential to monitor symptom improvement and medication side effects, which may include dizziness, retrograde ejaculation, or erectile dysfunction.
- Urodynamic testing may be necessary to further evaluate symptoms and guide treatment decisions.
- Patients should be informed about the potential risks and benefits of each treatment option, including the possibility of de novo or worsening OAB symptoms after BPH surgical interventions, as noted in the 2024 guideline 1.
From the FDA Drug Label
1.1 Monotherapy Finasteride tablets are indicated for the treatment of symptomatic benign prostatic hyperplasia (BPH) in men with an enlarged prostate to:
- Improve symptoms
- Reduce the risk of acute urinary retention
- Reduce the risk of the need for surgery including transurethral resection of the prostate (TURP) and prostatectomy.
Treatment of BPH Symptoms: Finasteride is indicated for the treatment of symptomatic BPH in men with an enlarged prostate. The symptoms of BPH include:
- Impairment of size and force of stream
- Sensation of incomplete bladder emptying
- Delayed or interrupted urination
- Nocturia
- Daytime frequency
- Need to strain or push the flow of urine
Effectiveness of Finasteride: Finasteride has been shown to improve symptoms of BPH, reduce the risk of acute urinary retention, and reduce the risk of the need for surgery. In a 4-year study, finasteride decreased the risk of acute urinary retention by 57% and the risk of surgery by 55% compared to placebo 2.
Key Benefits:
- Improves symptoms of BPH
- Reduces the risk of acute urinary retention
- Reduces the risk of the need for surgery
In a 4-Year Placebo-Controlled Study, finasteride was associated with a significantly lower risk for acute urinary retention or the need for BPH-related surgery compared with placebo 2.
Therefore, finasteride can be used to treat a yr old male with BPH having urinary issues.
From the Research
Treatment Options for BPH
- The treatment of benign prostatic hyperplasia (BPH) includes medical options such as 5alpha-reductase inhibitors (e.g., finasteride and dutasteride) and alpha1-adrenergic antagonists (e.g., doxazocin, terazosin, tamsulosin, and alfuzosin) 3.
- Combination therapy with a 5alpha-reductase inhibitor and an alpha1-adrenergic antagonist can significantly reduce the clinical progression of BPH over either drug class alone 3, 4, 5.
Effectiveness of Combination Therapy
- The CombAT trial showed that combination therapy with dutasteride and tamsulosin improved lower urinary tract symptoms (LUTS) to a significantly greater extent than dutasteride or tamsulosin alone in men with BPH and an enlarged prostate 4.
- The MTOPS study found that combination therapy with doxazosin and finasteride was significantly more effective than either component alone in reducing BPH-related symptoms and lowering the rate of overall clinical progression 6.
Adverse Effects of Pharmacological Therapy
- Pharmacological therapy of BPH can produce side effects on male sexual function, including disorders of ejaculation and orgasmic function 7.
- The main adverse effect on sexual function in men is the deterioration in ejaculation or the absence thereof, with combination therapy having the highest incidence of complete absence of ejaculation (23%) 7.