Medical treatment of benign prostatic hyperplasia
- Glenn R Cunningham, MD
Glenn R Cunningham, MD
- Professor of Medicine, Molecular and Cellular Biology
- Baylor College of Medicine
- Dov Kadmon, MD
Dov Kadmon, MD
- Professor of Urology
- Baylor College of Medicine
Benign prostatic hyperplasia (BPH) becomes increasingly common as men age. BPH can lead to urinary symptoms of increased frequency of urination, nocturia, hesitancy, urgency, and weak urinary stream. Symptomatic patients may benefit from medical or surgical treatment.
The medical therapy of BPH will be reviewed here. The clinical manifestations and diagnosis, epidemiology and pathogenesis, and surgical and other invasive therapies of BPH are all discussed separately. (See "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia" and "Epidemiology and pathogenesis of benign prostatic hyperplasia" and "Transurethral procedures for treating benign prostatic hyperplasia".)
Treatment of lower urinary tract symptoms in men from etiologies other than BPH is also discussed separately. (See "Lower urinary tract symptoms in men".)
INDICATIONS FOR THERAPY
Medical treatment — The decision to medically treat benign prostatic hyperplasia (BPH) balances the severity of the patient's symptoms with potential side effects of therapy. Unless patients have developed bladder outlet obstruction, BPH only requires therapy if symptoms have a significant impact on a patient's quality of life . Symptoms typically appear slowly and progress gradually over a period of years. Even without therapy, many men will experience stabilization or improvement in symptoms over time . (See "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia", section on 'Natural history'.)
For patients that require treatment, it is reasonable to initiate a trial of medical therapy for BPH when the clinician is comfortable that presenting signs and symptoms are consistent with BPH. (See "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia", section on 'Diagnostic approach'.)
- McVary KT, Roehrborn CG, Avins AL, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol 2011; 185:1793.
- Chapple CR. Pharmacological therapy of benign prostatic hyperplasia/lower urinary tract symptoms: an overview for the practising clinician. BJU Int 2004; 94:738.
- Burnett AL, Wein AJ. Benign prostatic hyperplasia in primary care: what you need to know. J Urol 2006; 175:S19.
- Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013; 64:118.
- de Jong Y, Pinckaers JH, ten Brinck RM, et al. Urinating standing versus sitting: position is of influence in men with prostate enlargement. A systematic review and meta-analysis. PLoS One 2014; 9:e101320.
- Brown CT, Yap T, Cromwell DA, et al. Self management for men with lower urinary tract symptoms: randomised controlled trial. BMJ 2007; 334:25.
- Roehrborn CG, Nuckolls JG, Wei JT, et al. The benign prostatic hyperplasia registry and patient survey: study design, methods and patient baseline characteristics. BJU Int 2007; 100:813.
- Black L, Naslund MJ, Gilbert TD Jr, et al. An examination of treatment patterns and costs of care among patients with benign prostatic hyperplasia. Am J Manag Care 2006; 12:S99.
- Djavan B, Marberger M. A meta-analysis on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction. Eur Urol 1999; 36:1.
- Tacklind J, Fink HA, Macdonald R, et al. Finasteride for benign prostatic hyperplasia. Cochrane Database Syst Rev 2010; :CD006015.
- MacDonald R, Wilt TJ, Howe RW. Doxazosin for treating lower urinary tract symptoms compatible with benign prostatic obstruction: a systematic review of efficacy and adverse effects. BJU Int 2004; 94:1263.
- MacDonald R, Wilt TJ. Alfuzosin for treatment of lower urinary tract symptoms compatible with benign prostatic hyperplasia: a systematic review of efficacy and adverse effects. Urology 2005; 66:780.
- Rees J, Bultitude M, Challacombe B. The management of lower urinary tract symptoms in men. BMJ 2014; 348:g3861.
- Garimella PS, Fink HA, Macdonald R, Wilt TJ. Naftopidil for the treatment of lower urinary tract symptoms compatible with benign prostatic hyperplasia. Cochrane Database Syst Rev 2009; :CD007360.
- Lee M. Tamsulosin for the treatment of benign prostatic hypertrophy. Ann Pharmacother 2000; 34:188.
- Roehrborn CG, Van Kerrebroeck P, Nordling J. Safety and efficacy of alfuzosin 10 mg once-daily in the treatment of lower urinary tract symptoms and clinical benign prostatic hyperplasia: a pooled analysis of three double-blind, placebo-controlled studies. BJU Int 2003; 92:257.
- Marks LS, Gittelman MC, Hill LA, et al. Rapid efficacy of the highly selective alpha1A-adrenoceptor antagonist silodosin in men with signs and symptoms of benign prostatic hyperplasia: pooled results of 2 phase 3 studies. J Urol 2009; 181:2634.
- Wilt TJ, Macdonald R, Rutks I. WITHDRAWN: Tamsulosin for benign prostatic hyperplasia. Cochrane Database Syst Rev 2011; :CD002081.
- Schwinn DA, Price DT, Narayan P. alpha1-Adrenoceptor subtype selectivity and lower urinary tract symptoms. Mayo Clin Proc 2004; 79:1423.
- Nieminen T, Tammela TL, Kööbi T, Kähönen M. The effects of tamsulosin and sildenafil in separate and combined regimens on detailed hemodynamics in patients with benign prostatic enlargement. J Urol 2006; 176:2551.
- Gacci M, Ficarra V, Sebastianelli A, et al. Impact of medical treatments for male lower urinary tract symptoms due to benign prostatic hyperplasia on ejaculatory function: a systematic review and meta-analysis. J Sex Med 2014; 11:1554.
- Giuliano F. Impact of medical treatments for benign prostatic hyperplasia on sexual function. BJU Int 2006; 97 Suppl 2:34.
- Nickel JC, Gilling P, Tammela TL, et al. Comparison of dutasteride and finasteride for treating benign prostatic hyperplasia: the Enlarged Prostate International Comparator Study (EPICS). BJU Int 2011; 108:388.
- Gormley GJ, Stoner E, Bruskewitz RC, et al. The effect of finasteride in men with benign prostatic hyperplasia. The Finasteride Study Group. N Engl J Med 1992; 327:1185.
- McConnell JD, Bruskewitz R, Walsh P, et al. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group. N Engl J Med 1998; 338:557.
- Roehrborn CG, Bruskewitz R, Nickel JC, et al. Sustained decrease in incidence of acute urinary retention and surgery with finasteride for 6 years in men with benign prostatic hyperplasia. J Urol 2004; 171:1194.
- Foley SJ, Soloman LZ, Wedderburn AW, et al. A prospective study of the natural history of hematuria associated with benign prostatic hyperplasia and the effect of finasteride. J Urol 2000; 163:496.
- Miller MI, Puchner PJ. Effects of finasteride on hematuria associated with benign prostatic hyperplasia: long-term follow-up. Urology 1998; 51:237.
- Wu XJ, Zhi Y, Zheng J, et al. Dutasteride on benign prostatic hyperplasia: a meta-analysis on randomized clinical trials in 6460 patients. Urology 2014; 83:539.
- Jeong YB, Kwon KS, Kim SD, Kim HJ. Effect of discontinuation of 5alpha-reductase inhibitors on prostate volume and symptoms in men with BPH: a prospective study. Urology 2009; 73:802.
- http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm258529.htm (Accessed on June 13, 2011).
- Tenover JL, Pagano GA, Morton AS, et al. Efficacy and tolerability of finasteride in symptomatic benign prostatic hyperplasia: a primary care study. Primary Care Investigator Study Group. Clin Ther 1997; 19:243.
- Wessells H, Roy J, Bannow J, et al. Incidence and severity of sexual adverse experiences in finasteride and placebo-treated men with benign prostatic hyperplasia. Urology 2003; 61:579.
- Matzkin H, Chen J, Weisman Y, et al. Prolonged treatment with finasteride (a 5 alpha-reductase inhibitor) does not affect bone density and metabolism. Clin Endocrinol (Oxf) 1992; 37:432.
- Jacobsen SJ, Cheetham TC, Haque R, et al. Association between 5-alpha reductase inhibition and risk of hip fracture. JAMA 2008; 300:1660.
- Liu L, Zheng S, Han P, Wei Q. Phosphodiesterase-5 inhibitors for lower urinary tract symptoms secondary to benign prostatic hyperplasia: a systematic review and meta-analysis. Urology 2011; 77:123.
- Oelke M, Giuliano F, Mirone V, et al. Monotherapy with tadalafil or tamsulosin similarly improved lower urinary tract symptoms suggestive of benign prostatic hyperplasia in an international, randomised, parallel, placebo-controlled clinical trial. Eur Urol 2012; 61:917.
- Porst H, Oelke M, Goldfischer ER, et al. Efficacy and safety of tadalafil 5 mg once daily for lower urinary tract symptoms suggestive of benign prostatic hyperplasia: subgroup analyses of pooled data from 4 multinational, randomized, placebo-controlled clinical studies. Urology 2013; 82:667.
- Roehrborn CG, Siami P, Barkin J, et al. The effects of dutasteride, tamsulosin and combination therapy on lower urinary tract symptoms in men with benign prostatic hyperplasia and prostatic enlargement: 2-year results from the CombAT study. J Urol 2008; 179:616.
- Lepor H, Williford WO, Barry MJ, et al. The efficacy of terazosin, finasteride, or both in benign prostatic hyperplasia. Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group. N Engl J Med 1996; 335:533.
- Debruyne FM, Jardin A, Colloi D, et al. Sustained-release alfuzosin, finasteride and the combination of both in the treatment of benign prostatic hyperplasia. European ALFIN Study Group. Eur Urol 1998; 34:169.
- Kirby RS, Roehrborn C, Boyle P, et al. Efficacy and tolerability of doxazosin and finasteride, alone or in combination, in treatment of symptomatic benign prostatic hyperplasia: the Prospective European Doxazosin and Combination Therapy (PREDICT) trial. Urology 2003; 61:119.
- McConnell JD, Roehrborn CG, Bautista OM, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med 2003; 349:2387.
- Füllhase C, Chapple C, Cornu JN, et al. Systematic review of combination drug therapy for non-neurogenic male lower urinary tract symptoms. Eur Urol 2013; 64:228.
- Morlock R, Goodwin B, Gomez Rey G, Eaddy M. Clinical progression, acute urinary retention, prostate-related surgeries, and costs in patients with benign prostatic hyperplasia taking early versus delayed combination 5α-reductase inhibitor therapy and α-blocker therapy: a retrospective analysis. Clin Ther 2013; 35:624.
- Roehrborn CG, Siami P, Barkin J, et al. The effects of combination therapy with dutasteride and tamsulosin on clinical outcomes in men with symptomatic benign prostatic hyperplasia: 4-year results from the CombAT study. Eur Urol 2010; 57:123.
- Roehrborn CG, Andriole GL, Wilson TH, et al. Effect of dutasteride on prostate biopsy rates and the diagnosis of prostate cancer in men with lower urinary tract symptoms and enlarged prostates in the Combination of Avodart and Tamsulosin trial. Eur Urol 2011; 59:244.
- Filson CP, Hollingsworth JM, Clemens JQ, Wei JT. The efficacy and safety of combined therapy with α-blockers and anticholinergics for men with benign prostatic hyperplasia: a meta-analysis. J Urol 2013; 190:2153.
- Tacklind J, Macdonald R, Rutks I, et al. Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev 2012; 12:CD001423.
- Wilt T, Ishani A, MacDonald R, et al. Beta-sitosterols for benign prostatic hyperplasia. Cochrane Database Syst Rev 2000; :CD001043.
- Wilt T, Mac Donald R, Ishani A, et al. Cernilton for benign prostatic hyperplasia. Cochrane Database Syst Rev 2000; :CD001042.
- Wilt T, Ishani A, Mac Donald R, et al. Pygeum africanum for benign prostatic hyperplasia. Cochrane Database Syst Rev 2002; :CD001044.
- INDICATIONS FOR THERAPY
- Medical treatment
- Urologic referral prior to medical treatment
- BEHAVIORAL MODIFICATIONS
- INITIAL MEDICAL MONOTHERAPY
- Alpha-1-adrenergic antagonists
- - Efficacy and administration
- - Side effects and interactions
- Alternative medications
- - 5-alpha-reductase inhibitors
- Side effects
- - Anticholinergic agents
- - PDE-5 inhibitors
- COMBINATION THERAPY
- Alpha-1-adrenergic antagonist and 5-alpha-reductase inhibitor
- Alpha-1-adrenergic antagonist and anticholinergic
- REFERRAL FOR INVASIVE THERAPY
- HERBAL THERAPIES
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS