BPH Medications

Alpha Adrenergic Blockers (Alpha blockers)

Rapaflo® (silodosin), Uroxatrol®(alfuzosin), Cardura® (doxazosin), Flomax® (tamsulosin) and Hytrin® (terazosin) are appropriate options for LUTS due to BPH.  All of the available alpha blocker medications have similar efficacy. Alpha blockers should be first-line therapy with bladder outlet obstruction symptoms.

The older, generic medications typically have a lower cost and with Doxazosin and Terazosin you will need to watch blood pressure and use dose titration.  With Tamsulosin you will not need to titrate dose and there will be less effect on blood pressure.

Indications

Alpha adrenergic blockers are indicated as first-line therapies for patients with moderate to severe lower urinary tract symptoms and for patients with indications for therapy and minor symptoms such as urinary tract infections or urinary retention.

Mechanism

Alpha blockers work by relaxing the muscles within the prostate and where the prostate joins the bladder making urination easier. They typically work quickly and improvement should occur in a few days to a week.

Results

Use of alpha blockers typically improves maximal flow rate from 2-3 ml/sec and improves I-PSS scores by 4-6 points. Each of the medications result in similar improvements, but some have less effect on blood pressure and should be preferentially utilized.

Side effects

• Dizziness
• Fatigue, weakness or lethargy.
• Orthostatic hypotension. Drop in blood pressure upon changing position. Typically a decrease in blood pressure when going from lying to sitting or sitting to standing. Often associated with lightheadedness.
• Retrograde ejaculation. A condition in which semen goes back into the bladder instead of out the tip of the penis. This may cause a change in sensation during ejaculation.

Safety

Intraoperative Floppy Iris Syndrome is a surgical condition which has been seen during cataract surgery in some patients who have been treated with alpha blockers. Most reports are in patients currently taking an alpha blocker, but some reports have also been made when the medication had been stopped prior to surgery. Patients with cataracts should let their ophthalmologist know they are thinking about using an alpha blocker before starting and may want to wait to begin therapy until after the cataracts have been treated.

5 Alpha-Reductase Inhibitors

Proscar® (Finasteride) and Avodart® (Dutasteride) are the available 5 Alpha-reductase inhibitors.  

Indications

5 Alpha-reductase inhibitors are indicated and appropriate treatment in men with LUTS and large prostates (More than 40 grams).  These medications are not appropriate for men with LUTS without evidence of significant prostatic enlargement. These medications shrink your prostate by preventing hormonal changes that cause prostate growth. And additional education is for patients with symptomatic prostate in large meant but no bother in order to prevent disease progression.

Finasteride is an effective and appropriate treatment for men with BPH and refractory hematuria thought to be of prostatic origin.

Symptomatic improvement may take up to six months to see full benefit.

Mechanism

Normal prostate development, as well as BPH progression, occurs under the influence of dihydrotestosterone (DHT), which is a derivative of testosterone.  Testosterone is converted to dihydrotestosterone in the prostate by 5 alpha reductase. 5 alpha reductase inhibitors thus block the conversion and thus cause prostatic “shrinkage” or involution of the prostate.  

Results

Use of 5 alpha reductase inhibitors is more efficacious in prostates that measure more than 40 grams in size.  Typical reduction in prostate size reduction was 18% and the decreased risk of surgery for acute urinary retention was nearly 60% and the need for BPH surgery was 50%.  Improvement in maximum flow rate was approximately 2 ml/second and I-PSS reduction was 2 points.

Side effects

A small percentage of men who take 5 alpha-reductase inhibitors have decreased sex drive, difficulty with erection or ejaculation, or symptoms of depression. Sometimes, these problems are significant enough to cause men to interrupt BPH treatment. They generally resolve when the medication is stopped.

PSA levels decrease by about 50 percent in men who take finasteride or dutasteride. This is important to remember if you have PSA testing to screen for prostate cancer.

Anti-Cholinergic Agents

The use of anticholinergic agents including anti-muscarinic and B3 agonists are appropriate and effective in men with predominately irritative symptoms without an elevated PVR.

Baseline PVR should be assessed prior to starting anticholinergic agents. If PVR is elevated these drugs should be used with caution.

Combination Drug Therapy

Concomitant use of an alpha blocker and a 5-alpha reductase inhibitor is appropriate and effective treatment for patients with urinary symptoms associated with demonstrably large prostate Jalyn® (tamsulosin and dutasteride)

Occasionally a medication that helps inhibit bladder overactivity (anti-muscarinic or B3 agonist) is used with an alpha blocker.  

What about Cialis?

Studies suggest Cialis® (tadalafil), which is often used to treat erectile dysfunction, can also treat BPH.  

Side effects

• Facial flushing
• Headache
• Runny Nose
• Upset stomach
• Nausea

Supplements for lower urinary tract symptoms. Most supplements for BPH are herbal or phytotherapeutic therapies.  

According to the AUA guidelines no dietary supplement, combination find a therapeutic agent or non-conventional therapy is recommended for the management of lower urinary tract symptoms secondary to BPH.

There is not enough evidence showing that supplements significantly help BPH.  Most supplements contain saw palmetto and beta sitosterol. Currently, there are clinical trials underway to evaluate the efficacy of saw palmetto.