What is the first line treatment for Benign Prostatic Hyperplasia (BPH)?

From the Guidelines

The first line treatment for benign prostatic hyperplasia (BPH) typically involves alpha-blockers such as tamsulosin (0.4 mg daily), alfuzosin (10 mg daily), or silodosin (8 mg daily), as recommended by the most recent guidelines 1. These medications relax the smooth muscle in the prostate and bladder neck, improving urine flow and reducing symptoms like frequency, urgency, and nocturia. They work quickly, often within days to weeks. For men with larger prostates (>40g), 5-alpha reductase inhibitors like finasteride (5 mg daily) or dutasteride (0.5 mg daily) may be added or used alone, as they shrink the prostate by blocking the conversion of testosterone to dihydrotestosterone, but take 3-6 months for full effect 1. Combination therapy with both medication classes may be more effective for men with moderate-to-severe symptoms and enlarged prostates, as shown in studies such as the CombAT study [@27@, @28@]. Phosphodiesterase-5 inhibitors like tadalafil (5 mg daily) are also FDA-approved for BPH, especially in men with concurrent erectile dysfunction. Some key points to consider when treating BPH include:

• The importance of prostate size in determining treatment efficacy, with 5-alpha reductase inhibitors being more effective in men with larger prostates [@36@, @37@]
• The potential for combination therapy to improve outcomes in men with moderate-to-severe symptoms and enlarged prostates [@27@, @28@]
• The need for lifestyle modifications to accompany medication, including limiting evening fluid intake, reducing alcohol and caffeine consumption, and avoiding medications that worsen symptoms (like decongestents and antihistamines) [@22@, @23@]
• The potential benefits and risks of different treatment options, including the risk of intraoperative floppy iris syndrome with tamsulosin [@33@] and the potential for dutasteride to improve objective and subjective disease measures in men with BPH and modest or severe prostate enlargement [@35@, @38@]. Lifestyle modifications should accompany medication, including limiting evening fluid intake, reducing alcohol and caffeine consumption, and avoiding medications that worsen symptoms (like decongestants and antihistamines).

From the FDA Drug Label

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.

Dutasteride capsules 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 (AUR), and reduce the risk of the need for BPH-related surgery.

UROXATRAL is a prescription medicine that is called an "alpha-blocker". UROXATRAL is used in adult men to treat the symptoms of benign prostatic hyperplasia (BPH).

The first line treatment for BPH includes:

• Finasteride 2
• Dutasteride 3
• Alfuzosin 4

These medications are used to improve symptoms, reduce the risk of acute urinary retention, and reduce the risk of the need for surgery.

From the Research

First Line Treatment for BPH

The first line treatment for Benign Prostatic Hyperplasia (BPH) typically involves the use of medications to alleviate symptoms and improve quality of life.

• Alpha-blockers: These are often used as the first line treatment for BPH, as they have been shown to be effective in relieving lower urinary tract symptoms (LUTS) and improving maximal urinary flow rate 5, 6, 7, 8.
• 5-alpha-reductase inhibitors (5ARIs): These may also be used, particularly in patients with an enlarged prostate, as they have been shown to reduce prostate size and prevent disease progression in the long term 5, 9.
• Combination therapy: Combination therapy with an alpha-blocker and a 5ARI may be beneficial in patients who require immediate relief of symptoms, with discontinuation of the alpha-blocker after several months of therapy 5, 9.

Factors Influencing Treatment Choice

The choice of treatment may depend on various factors, including:

• Prostate size: Patients with an enlarged prostate may benefit from 5ARIs or combination therapy 5, 9.
• Symptom severity: Patients with more severe symptoms may benefit from combination therapy or alpha-blockers 5, 8.
• PSA levels: Patients with higher PSA levels may benefit from combination therapy or 5ARIs 5.
• Presence of prostatic inflammation: Patients with prostatic inflammation may benefit from combination therapy 5.