drug treatment in benign prostatic hyperplasia

Last edited 12/2018 and last reviewed 07/2021

The principle agents used in management of benign prostatic hypertrophy are:

• alpha-adrenoceptor blocking agents:
• relax the proximal urethra and improve urinary flow
• for example prazosin, terazosin, alfuzosin, tamsulosin, indoramin
• 5 alpha-reductase inhibitors:
• for example dustateride, finasteride

At present alpha blockers remain the drug of first choice for the management of benign prostatic hypertrophy, whereas 5 alpha-reductase inhibitors do not seem to be as effective at relieving symptoms, although there may be a benefit when there is substantial prostatic enlargement

• 5alpha - reductase inhibitors have been shown to prevent progression of symptoms and need for surgery

NICE suggest that (1)

• an alpha blocker (alfuzosin, doxazosin, tamsulosin or terazosin) should be offered to men with moderate to severe LUTS
  
  
• an 5-alpha reductase inhibitor to men with LUTS should be offered to men who have prostates estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml, and who are considered to be at high risk of progression (for example, older men)
  
  
• a combination of an alpha blocker and a 5-alpha reductase inhibitor should be considered for men with bothersome moderate to severe LUTS and prostates estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml
  
  
• consider offering an anticholinergic as well as an alpha blocker to men who still have storage symptoms after treatment with an alpha blocker alone
  
  
• consider offering a late afternoon loop diuretic to men with nocturnal polyuria *
  
  
• consider offering oral desmopressin* to men with nocturnal polyuria if other medical causes** have been excluded and they have not benefited from other treatments. Measure serum sodium 3 days after the first dose. If serum sodium is reduced to below the normal range, stop desmopressin treatment
  
  

• review men taking drug treatments to assess symptoms, the effect of the drugs on the patient's quality of life and to ask about any adverse effects from treatment

• review men taking alpha blockers at 4-6 weeks and then every 6-12 months

• review men taking 5-alpha reductase inhibitors at 3-6 months and then every 6-12 months

Notes:

• *at the time of publication (June 2015), loop diuretics (for example, furosemide) did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented
• ** medical conditions that can cause nocturnal polyuria symptoms include diabetes mellitus, diabetes insipidus, adrenal insufficiency, hypercalcaemia, liver failure, polyuric renal failure, chronic heart failure, obstructive apnoea, dependent oedema, pyelonephritis, chronic venous stasis, sickle cell anaemia. Medications that can cause nocturnal polyuria symptoms include calcium channel blockers, diuretics, selective serotonin reuptake inhibitors (SSRI) antidepressants.

Reference:

• 1) NICE (June 2015). Lower urinary tract symptoms The management of lower urinary tract symptoms in men