Comprehensive Guide to Manage Benign Prostatic Hyperplasia (BPH) in Men

About 6 in 10 men develop benign prostatic hyperplasia (BPH) by age 60, leading to urinary hesitancy, nocturia, and a weak stream. Emphasize nondrug measures such as limiting fluids at bedtime, alcohol, and caffeine. Reinforce exercise to strengthen pelvic floor muscles, which may improve bladder control and urination. Assess for constipation and treat it if necessary. Identify and consider alternatives for exacerbating medications, such as diuretics or anticholinergics (e.g., oxybutynin).

Start with tamsulosin or another alpha-blocker for most patients. All are modestly effective and can start working within a few days. Choose based on side effects. Ejaculatory dysfunction is most likely with silodosin (Flopadex, Sympaprost) or tamsulosin (Omnic, Tamsul) and least likely with alfuzosin SR (Xatral SR, Alfatral SR).

• Note that doxazosin (Cardura, Dosin) and terazosin (Itrin, Terazin) are on the Beers Criteria due to dizziness and hypotension.
• 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. Explain that these 5-alpha-reductase inhibitors take 6 to 12 months for maximum effects.

• Caution about gynecomastia, sexual dysfunction, and a potential link to an increased risk of high-grade prostate cancer.
• These medications can lower prostate-specific antigen (PSA) levels and may delay diagnosis.
• Instruct caregivers to avoid handling dutasteride or broken/crushed finasteride tabs during pregnancy due to possible risks to a male fetus.

Consider trying tadalafil (Cialis, Cialong) 5 mg daily, especially if erectile dysfunction is also a problem. This PDE5 inhibitor has the most evidence for BPH but should not be prescribed PRN for this use. Avoid combining daily tadalafil with an alpha-blocker due to the increased risk of hypotension and lack of additional efficacy. It is acceptable to add tadalafil to a 5-alpha-reductase inhibitor. FDA approved Entadfi (finasteride/tadalafil) on December 9, 2021. Expect this combo to cost more than giving the medications separately.

If patients inquire about saw palmetto (Pepon, Pepon Plus), inform them it’s okay to try, but it doesn’t seem to have much benefit for BPH.

Take-home points

Effective management of BPH can greatly improve patient outcomes...

1. Emphasize nondrug measures such as limiting bedtime fluids, alcohol, and caffeine.
2. Reinforce exercise and strengthening pelvic floor muscles to improve bladder control.
3. Start with tamsulosin or another alpha-blocker to alleviate BPH symptoms.
4. Add dutasteride (Avodart) or finasteride (Proscar) if symptoms persist after 4 to 12 weeks.
5. Consider tadalafil (Cialis) 5 mg daily for BPH and erectile dysfunction.
6. Advise caution with saw palmetto, as it shows limited benefit for BPH.

References

Keywords: Benign prostatic hyperplasia, BPH management, Alpha-blockers, Tamsulosin, Dutasteride, Finasteride, Tadalafil for BPH, Pelvic floor exercises, Non-drug BPH treatments, Prostate health