About 6 in 10 men develop benign prostatic hyperplasia (BPH) by age 60 leading to urinary hesitancy, nocturia, a weak stream, etc. Emphasize nondrug measures, such as limiting fluids at bedtime, alcohol, and caffeine. Reinforce exercise, strengthening pelvic floor muscles may improve bladder control and urination. Also assess for constipation and treat it if necessary. And look for exacerbating medications, such as diuretics or anticholinergics (oxybutynin, etc) and consider alternatives.
Start with tamsulosin or another alpha-blocker in most patients. All are modestly effective and can start working in just a few days. Choose one based on side effects. For example, ejaculatory dysfunction is most likely with silodosin (Flopadex, Sympaprost) or tamsulosin (Omnic, Tamsul) and least likely with alfuzosin SR (Xatral SR, Alfatral SR). Doxazosin (Cardura, Dosin) and terazosin (Itrin, Terazin) are on the Beers Criteria (see PDF, available at; https://dcri.org/wp-content/uploads/2016/11/2012AGSBeersCriteriaCitations.pdf) due to dizziness and hypotension. But keep in mind, any alpha-blocker can cause orthostatic hypotension and raise fall risk. Advise rising slowly, especially with the first dose.
Usually add dutasteride (Avodart) or finasteride (Proscar) to an alpha-blocker if BPH symptoms don’t improve after 4 to 12 weeks. But explain that these 5-alpha-reductase inhibitors take 6 to 12 months for max effects. Caution about gynecomastia and sexual dysfunction and a link with an increased risk of high-grade prostate cancer. These medications can lower prostate-specific antigen (PSA) levels and may delay diagnosis. Tell caregivers to avoid handling dutasteride (Avodart) or broken or crushed finasteride (Proscar) tabs during pregnancy due to possible risk to a male fetus.
Consider trying tadalafil (Cialis, Cialong) 5 mg daily, especially if erectile dysfunction is also a problem. This is the PDE5 inhibitor with the most evidence for BPH, but don’t prescribe it PRN for this use. And don’t add daily tadalafil (Cialis, Cialong) to an alpha-blocker. The combo doesn’t seem more effective and may increase hypotension risk. It is okay to add tadalafil (Cialis, Cialong) to a 5-alpha-reductase inhibitor. FDA approved Entadfi (finasteride/tadalafil) in December 9, 2021. But expect this combo to cost much more than giving the medications separately. If patients ask about saw palmetto (Pepon, Pepon Plus), tell them it’s okay to try, but doesn’t seem to have much benefit for BPH.
REFERENCES
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Pearson, R. and Williams, P.M. (2014). Common Questions About the Diagnosis and Management of Benign Prostatic Hyperplasia. American Family Physician, [online] 90(11), pp.769–774. Available at: http://www.aafp.org/afp/2014/1201/p769.html
Lerner LB, McVary KT, Barry MJ, Bixler BR, Dahm P, Das AK, Gandhi MC, Kaplan SA, Kohler TS, Martin L, Parsons JK, Roehrborn CG, Stoffel JT, Welliver C, Wilt TJ. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART I-Initial Work-up and Medical Management. J Urol. 2021 Oct;206(4):806-817. Available at: https://www.auajournals.org/doi/10.1097/JU.0000000000002183
American Urology Association. American Urology Association Guideline: Management of benign prostatic hyperplasia (BPH). AUA. Available at: https://www.auanet.org/education/guidelines/benign-prostatic-hyperplasia.cfm
Pattanaik S, Mavuduru RS, Panda A, Mathew JL, Agarwal MM, Hwang EC, Lyon JA, Singh SK, Mandal AK. Phosphodiesterase inhibitors for lower urinary tract symptoms consistent with benign prostatic hyperplasia. Cochrane Database Syst Rev. 2018 Nov 16;11(11):CD010060. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010060.pub2/full
Cantrell, M.A., Baye, J. and Vouri, S.M. (2013). Tadalafil: a phosphodiesterase-5 inhibitor for benign prostatic hyperplasia. Pharmacotherapy, [online] 33(6), pp.639–649. Available at: http://www.ncbi.nlm.nih.gov/pubmed/?term=23529917