Benign Prostatic Hyperplasia

I. Background
a. Prostate enlarges and obstructs urethrae and disrupts urine flow
b. Androgen hormones cause prostate to enlarge
c. Testosterone is converted to dihydrotestosterone via 5 alpha reductase
d. Happens mostly in men greater than 65 years of age
e. BPH
i. Direct bladder outlet obstruction (BOO)
ii. Lower urinary tract symptoms (LUTS)
II. Diagnosis
a. Digital rectal exam (DRE)
+
b. Prostate specific antigen (PSA)
i. In BPH you have an increased PSA
ii. BPH does not mean it will lead to prostate cancer
c. Both used to rule out cancer

Key Drugs That Can Worsen BPH

Anticholinergics (e.g. benztropine)
Antihistamines (e.g. diphenhydramine)
Caffeine
Decongestants (e.g. Pseudoephedrine)
Diuretics
SNRIs
TCAs and phenothiazines
Testosterone products
Note: Pseudoephedrine and antihistamines are in common OTC meds. Treat with something like a nasal
antihistamine or decongestant instead. Norepinephrine and epinephrine release during a fight or flight
response you are not stopping to go to the bathroom due to the vasoconstriction. Acetylcholine causes
relaxation and you can urinate, so anticholinergics act more like norepi and epi.

III. Symptoms and Complications

a. LUTS
i. Hesitancy
ii. Straining
iii. Weak urine system
iv. Urgency
v. Leaking/dribbling
vi. Increased frequency
vii. Nocturia
viii. Incomplete emptying
IV. Treatment Principles
a. Patient fills out a form before treatment
i. International prostate symptom score (I-PSS)
ii. American Urological Association Symptom Score (AUASS)
 b. Symptoms guide treatment
i. Watching and waiting
ii. Medications
iii. Procedures (surgery, TURP)
c. Natural Products
i. Not recommended for BPH
ii. Saw palmetto, lycopene, others
1. Rated as not effective in natural medicine database
iii. Caution: symptoms should be evaluated rather than self-treated
V. Drug Treatment: Alpha Blockers
a. First line (+/- 5 alpha-reductase inhibitors)
i. Add on 5a-reductase depending on symptoms
b. Attach to alpha-1 receptors in the smooth muscle walls causing relaxation and
improving urinary flow
c. Non-selective vs. selective
i. Non-selective drops blood pressure and cause orthostatic hypotension and
dizziness
1. Doxazosin
2. Terazosin’s
ii. Selective doesn’t have these side effects
1. tamsulosin
d. Intraoperative floppy iris syndrome
i. Occurs during cataracts surgery since we have alpha receptors in our eye if you
take alpha blockers it will make your eye look relaxed and floppy
VI. Alpha Blockers
a. Non-Selective Alpha Blockers: Terazosin, Doxazosin (Cardura XL)
i. Titrate slowly
1. Start doxazosin at 1mg
ii. Give at bedtime
b. Selective Alpha Blockers
i. No need to titrate these
ii. Tamsulosin (Flomax): 0.4 mg once daily;
+ dutasteride (Jalyn) (5-alpha reductase inhibitor)
iii. Alfuzosin: QT prolongation
iv. Silodosin: retrograde ejaculation
1. Ejaculation goes in wrong direction
c. Caution with PDE-5 inhibitors
i. Combo will cause more hypotension
VII. Drug Treatment: 5 Alpha Reductase Inhibitors
a. Finasteride (Proscar)
b. Dutasteride (Avodart) + tamsulosin (Jalyn)
i. Alpha blockers work faster so can be used to bridge into 5-alpha reductase
inhibitors
c. Shrink the prostate and decrease PSA levels
 i. Blocks 5-alpha reductase and stops the conversion of testosterone to
dihydrotestosterone
ii. Help stop the source of prostate enlargement unlike alpha blockers which just
direct stop smooth muscle growth
d. Side effects: impotence, libido, breast enlargement/tenderness
e. Hazardous drug
i. Hormone type drug so has side effects listed above
VIII. Drug Treatment: Phosphodiesterase-5 (PDE-5) Inhibitor
a. Tadalafil (Cialis)
b. Safety
i. Contraindications: nitrates, riociguat
1. Riociguat used for pulmonary hypertension
ii. Warnings:
1. Hearing/vision loss
a. Tinnitus, color discrimination
2. Hypotension/chest pain
3. Priapism
a. More than 4 hours should get medical attention
iii. Side effects
1. Headache, flushing, dizziness
2. Don’t use with alpha blockers