Medical treatment of BPH

Mild or minimally bothersome symptoms

Watchful waiting may be used, accompanied by:

• Education.
• Lifestyle modification.
• Reduction of nighttime fluids.
• Moderation of caffeine and alcohol.
• Clinical follow-up.

Alpha-blockers

Examples: tamsulosin, silodosin, alfuzosin, doxazosin, terazosin.

They act by reducing the tone of prostatic and urethral smooth muscle. They have a relatively rapid onset of action. They improve symptoms, but do not significantly reduce prostate size or, on their own, prevent progression.

5-alpha-reductase inhibitors

Examples: finasteride, dutasteride.

They decrease the conversion of testosterone to dihydrotestosterone. They progressively reduce prostate volume and lower the risk of:

• Progression.
• Urinary retention.
• Need for surgery.

They are mainly used in patients with moderate or severe LUTS and an enlarged prostate at risk of progression. Their effect is slow and may take several months.

Tadalafil

Tadalafil 5 mg/day can improve LUTS and is especially useful when erectile dysfunction coexists.

Predominantly storage symptoms

In selected patients, the following may be used:

• Antimuscarinics.
• Beta-3 agonists.

The risk of retention and the postvoid residual must be assessed.

Combination therapy

An alpha-blocker + a 5-alpha-reductase inhibitor may be used in patients with:

• Moderate or severe symptoms.
• Enlarged prostate.
• Higher risk of progression.

The combination improves symptoms and, in the long term, reduces the risk of urinary retention and surgery.

Quick choice

1. Need for rapid symptom relief → alpha-blocker.
2. Enlarged prostate + risk of progression → 5-ARI ± alpha-blocker.
3. LUTS + erectile dysfunction → consider tadalafil.
4. Predominance of storage symptoms → consider specific storage-symptom treatment.