Benign prostatic hyperplasia (BPH) is a condition that commonly affects men as they age. It is characterized by the enlargement of the prostate gland, which can lead to urinary symptoms such as frequent urination, weak stream, urgency, and difficulty emptying the bladder. Fortunately, there are many medications available to help manage BPH symptoms and improve urinary function.

There are two categories of medications for treating BPH: alpha-blockers and 5-alpha reductase inhibitors. Alpha-blockers work by relaxing the prostate and bladder neck’s smooth muscle, which improves urine flow and reduces symptoms. They are often prescribed as the first-line treatment for BPH, especially in men with moderate to severe symptoms. 

In contrast, 5-alpha reductase inhibitors work by blocking testosterone’s conversion to dihydrotestosterone (DHT), a hormone that contributes to prostate growth. These medications can slow BPH progression, reduce prostate size, and improve urinary symptoms over time. 

Treatment Options For BPH

BPH cannot be prevented but it can be managed by behavioral changes, lifestyle modification, medications, and surgery.

Lifestyle modification

Patients with mild symptoms of BPH can try this method. Some simple steps that can help improve symptoms include: 

• Decreasing fluid intake before bedtime or travel
• Avoid drinks that increase urination like caffeine and alcohol
• Avoid highly seasoned or irritative foods
• Perform regular exercises 
• Reduce body weight
• Practice pelvic floor muscle strengthening exercises 

Medical Management 

If lifestyle modifications do not help alleviate the symptoms, medical management can be tried. Medications are often the first-line treatment for mild to moderate BPH symptoms, and they can improve urinary function and quality of life for many men. 

Various therapies are available to relieve the symptoms of benign prostatic hyperplasia (BPH), including alpha-1 adrenergic receptor blockers, phosphodiesterase 5 blockers, beta-3 adrenergic agonists, and anticholinergics [1].

Alpha 1 Adrenergic Receptor Blockers

Alpha 1 adrenergic receptor blockers such as prazosin, terazosin, alfuzosin, tamsulosin, and silodosin, work by relaxing the muscles of the urinary bladder neck, and prostatic urethra to increase urine flow. While side effects like dizziness and rhinitis are possible, some drugs in this category can also be used to manage high blood pressure. 

People taking this group of medications should get their blood pressure checked regularly. Certain agents have a lower risk of hypotension, such as tamsulosin, alfuzosin, and silodosin, compared to others like terazosin and doxazosin. Tamsulosin and silodosin are associated with a higher frequency of retrograde or anejaculation, also known as a dry orgasm [2].

Phosphodiesterase 5 Blockers 

Phosphodiesterase 5 blockers like sildenafil and tadalafil may relieve BPH symptoms, but they are often used in combination with other drugs, especially in patients with sexual dysfunctions. 

Tadalafil is the only FDA-approved drug in this category for BPH, and common side effects include headache, flushing, nasal congestion, and sinusitis. Studies have shown that these drugs can relieve symptoms of BPH, but they did not show promising results in the improvement of urinary flow.

Beta-3 Adrenergic Agonists

Beta-3 adrenergic agonists, such as mirabegron and vibegron, work by relaxing the muscle of the urinary bladder, which helps to relieve overactive bladder symptoms like urgency and increased frequency. These medications may be preferred over anticholinergic agents because they do not cause dryness in the mouth.

However, men receiving beta-3 adrenergic agonists should have their blood pressure monitored regularly because these drugs can raise blood pressure. While they are less commonly prescribed than other BPH medications, they may be a suitable option for patients who do not respond well to other therapies or have contraindications to other medications.

Anticholinergics

Anticholinergics, including fesoterodine, tolterodine, and oxybutynin, also relax the bladder muscle and relieve irritative urinary symptoms. However, these drugs are associated with a range of side effects, including dry mouth, constipation, dyspepsia, blurred vision, urinary retention, headache, and somnolence. They may also increase the risk of urinary retention in patients with a post-void residual volume greater than 300ml, so they should be avoided in these patients.

Overall, the choice of BPH medication depends on the patient’s individual symptoms and health status, as well as potential side effects and drug interactions. A healthcare provider can help determine the best course of treatment for each patient.

5-Alpha Reductase Inhibitors 

5-alpha reductase inhibitors (5ARIs) work by preventing the conversion of testosterone to its active form dihydrotestosterone (DHT), which can contribute to prostate growth. This mechanism of action makes them effective in reducing the size of the prostate and relieving associated symptoms. 

Two examples of 5ARIs are finasteride and dutasteride, and it’s important to note that treatment with these drugs should be continued indefinitely to prevent symptom relapse. While 5ARIs are effective in reducing the size of the prostate, a meta-analysis conducted in 2010 suggested that alpha-1 adrenergic antagonists may be more effective than 5ARIs in terms of both short-term and long-term outcomes [3].

Ultimately, the choice of medication for BPH depends on a variety of factors, including the severity of symptoms, the size of the prostate, and the presence of other medical conditions. A healthcare provider can help determine the most appropriate treatment plan for each individual patient.

Side Effects Of BPH Medications

BPH medications can cause several side effects that patients should be aware of before starting treatment. 

Sexual Dysfunction

Patients taking tamsulosin or silodosin may experience retrograde or anejaculation (dry orgasm), while finasteride and dutasteride can cause erectile dysfunction, decreased libido, and premature ejaculation.

Progression to Cancer

Studies have shown a decreased incidence of prostate cancer after using finasteride or dutasteride. However, in some cases, high-grade cancer was detected, which could be due to detection bias.

Reduction of PSA

Finasteride or dutasteride can significantly decrease PSA levels by almost 50%, so it is important to determine PSA levels before starting treatment with 5ARIs.

Contraindications

While BPH medications are effective in treating the symptoms of the condition, they are not without contraindications. In certain cases, the medications may worsen the symptoms or cause adverse reactions in patients. Therefore, it is important to consider the contraindications before prescribing these medications to patients.

Alpha-adrenergic blockers, such as tamsulosin and alfuzosin, are contraindicated in patients with a history of orthostatic hypotension or syncope. These medications may cause a sudden drop in blood pressure, especially upon standing, leading to falls and other complications.

Similarly, 5-alpha reductase inhibitors, such as finasteride and dutasteride, are contraindicated in patients with liver disease or those taking medications that affect liver function. These medications can cause liver damage and should not be prescribed to patients with a history of liver disease or elevated liver enzymes.

Anticholinergics, such as tolterodine and oxybutynin, are contraindicated in patients with urinary retention, gastric retention, or uncontrolled narrow-angle glaucoma. These medications may exacerbate urinary retention and increase intraocular pressure, leading to complications such as urinary tract infections and vision problems.

Phosphodiesterase inhibitors, such as sildenafil and tadalafil, are contraindicated in patients taking nitrates for angina or those with severe liver or kidney disease. These medications may interact with nitrates, leading to a sudden drop in blood pressure, and should not be used in patients with severe liver or kidney disease.

Herbal remedies, such as saw palmetto and pygeum africanum, may interact with other medications and should not be used in patients taking anticoagulants or antiplatelet medications. These herbal remedies can increase the risk of bleeding and should be used with caution in patients with bleeding disorders.

In conclusion, BPH medications are effective in treating the symptoms of the condition, but it is important to consider the contraindications before prescribing them to patients. Patients with a history of certain medical conditions or those taking certain medications may be at risk of adverse reactions or worsening of symptoms and should be monitored closely while on these medications.

BPH Medications Usage In Patients With Other Comorbidities

BPH patients may have other comorbidities that can aggravate their symptoms. Medications used for the common cold containing alpha-adrenergic agonists like decongestants with pseudoephedrine can increase bladder outlet resistance by causing bladder neck and prostatic smooth muscle contraction.

Anticholinergic medications and calcium channel blockers like amlodipine and nifedipine can prevent complete bladder emptying by promoting bladder relaxation. Diuretics like furosemide or thiazides can cause urinary frequency when taken during the day and nocturia when taken at bedtime.

Congestive heart failure and diabetes can cause nocturia and increased urinary frequency, while neurogenic bladder conditions like Parkinson’s disease, brain tumor, spinal cord injury, and peripheral neuropathy (due to diabetes, alcoholism, vitamin B12 deficiency) can also have lower urinary tract symptoms similar to BPH. 

Combination Therapy

Combination therapy for BPH involves the use of two or more drugs to manage the symptoms. One combination therapy involves the use of alpha-adrenergic blockers, such as tamsulosin, and 5 alpha-reductase inhibitors, such as finasteride, if there is no adequate improvement in symptoms. This combination has been shown to significantly improve urine flow, but the reduction in prostate volume is similar to using finasteride alone. 

Another combination therapy is the use of an alpha-adrenergic blocker with a beta-3 agonist or anticholinergic if there are persistent bladder overactive features like frequency and urgency. In patients experiencing sexual dysfunction, especially erectile dysfunction, finasteride, and tadalafil are combined [4]. 

Alternative Therapies

Herbal remedies have also been studied for their effectiveness in alleviating BPH symptoms. However, there is a lack of larger studies with appropriate study designs to ascertain their efficacy and safety. 

Some of the herbs that have been studied for their use in BPH include saw palmetto or Serenoa repens, common nettle or Urtica dioica, acorn squash or Cucurbita pepo, lycopene, African plum or Pygeum africanum, and flaxseed or Linum usitatissimum [5]. 

These herbs are believed to decrease inflammation of the prostate gland, thus relieving BPH symptoms. However, more research is needed to confirm their effectiveness.

Surgery: When To Opt For Surgery?

If patients do not respond adequately to medical management, then surgical resection of the prostate is an option. 

Transurethral resection of the prostate is a commonly practiced surgical method. A simple prostatectomy is done in the larger prostate. Newer modalities including transurethral laser vaporization, ablation, and enucleation are also developing rapidly.

The Takeaway

In conclusion, BPH medications aim to improve urinary symptoms and quality of life in patients with BPH. Treatment options include alpha-adrenergic blockers, 5-alpha reductase inhibitors, beta-3 agonists, and anticholinergic medications. 

Combination therapy may be considered in patients with persistent symptoms. It is important to monitor for potential side effects and to manage comorbidities that may worsen BPH symptoms. 

While some herbal remedies may provide symptomatic relief, their efficacy and safety remain uncertain and larger studies are needed. Overall, a personalized approach based on individual patient characteristics and preferences is recommended when selecting BPH medications.

References Cited In This Article

1. Carbone, A., et al. “Management of lower urinary tract symptoms associated with benign prostatic hyperplasia in elderly patients with a new diagnostic, therapeutic and care pathway.” European Urology Supplements 3.16 (2017): e1164-e1166.
2. Lepor, Herbert. “Phase III multicenter placebo-controlled study of tamsulosin in benign prostatic hyperplasia.” Urology 51.6 (1998): 892-900.
3. Gormley, Glenn J., et al. “The effect of finasteride in men with benign prostatic hyperplasia.” New England Journal of Medicine 327.17 (1992): 1185-1191.
4. McVary, Kevin T. “A review of combination therapy in patients with benign prostatic hyperplasia.” Clinical therapeutics 29.3 (2007): 387-398.
5. Leisegang, Kristian, et al. “A systematic review of herbal medicine in the clinical treatment of benign prostatic hyperplasia.” Phytomedicine Plus 2.1 (2022): 100153.