Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
alpha-blocker + behavioural management programme
In general, offer medical therapy as first-line management for patients with bothersome, moderate to severe symptoms of BPH who do not require surgery (i.e., absence of complications attributed to BPH, such as renal insufficiency, bladder stones, recurrent haematuria or urinary tract infections, or refractory urinary retention; no wish for surgery as primary treatment).[17]
Patients may also benefit from behavioural and lifestyle modifications including reducing fluids at night and before travel, limiting caffeinated and alcoholic drinks, avoiding or modifying the timing of diuretics or medications that increase urinary retention, preventing or treating constipation, and use of techniques to help control bladder symptoms (e.g., bladder training, pelvic floor exercises).[17][18]
Offer an alpha-blocker as initial therapy for most patients with moderate to severe symptoms of BPH.[17][18] Different alpha-blockers (e.g., alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin) have similar efficacy. Base the choice of alpha-blocker on patient age, comorbidities, and adverse event profile.[17][35]
Alpha-blockers work through smooth muscle relaxation in the prostate and bladder neck. The predominant receptor type in the prostate and bladder is the alpha-1A receptor. Alpha-blockers are effective within a few days and usually well tolerated.[34]
Long-acting alpha-1 blockers include terazosin and doxazosin. Terazosin and doxazosin are titrated to avoid first-dose hypotension and syncope (first-dose effect). Alfuzosin is a short-acting alpha-1 blocker that is available as a modified-release formulation. Tamsulosin and silodosin are long-acting sub-type (alpha-1A) selective alpha-blockers, which may result in modest improvements in symptom scores and peak urinary flow rate (Qmax). Silodosin is a more selective alpha-1A blocker than tamsulosin, and has shown superiority over placebo, with significant improvements in symptom scores at 12 weeks.[36]
Ejaculatory dysfunction and an increase in unwanted sexual adverse effects are frequently reported adverse events with silodosin and may also occur with tamsulosin.[36]
[ 
]
Alfuzosin, doxazosin, and terazosin are associated with a low risk of ejaculatory dysfunction and may, therefore, be preferred in younger or more sexually active men.[17][18] Silodosin may be preferred in individuals taking numerous antihypertensives or those with orthostatic hypertension due to its minimal impact on blood pressure.[18]
Use of alpha-blockers is associated with floppy iris syndrome, which can cause technical difficulties during cataract surgery. Risk was found to be highest with tamsulosin. Patients should be asked about any potential eye surgery prior to initiating therapy.[17][18]
Men taking prostate-specific alpha-blockers have been shown to have significantly increased risks of falling and fracture, as well as increased risk of hypotension and head trauma.[37]
Men with BPH treated with an alpha-blocker, alone or in combination with a 5-alpha-reductase inhibitor, may be at increased risk for heart failure compared with no medication use; non-selective alpha-blockers appear to be associated with a higher risk of heart failure than selective alpha-blockers.[38]
Primary options
terazosin: 1 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day given in 2 divided doses
OR
doxazosin: 1 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 8 mg/day; 4 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 8 mg/day
OR
alfuzosin: 10 mg orally once daily (extended-release)
OR
tamsulosin: 0.4 mg orally once daily initially, increase gradually according to response, maximum 0.8 mg/day
OR
silodosin: 8 mg orally once daily
phosphodiesterase-5 (PDE-5) inhibitor + behavioural management programme
In general, offer medical therapy as first-line management for patients with bothersome, moderate to severe symptoms of BPH who do not require surgery (i.e., absence of complications attributed to BPH, such as renal insufficiency, bladder stones, recurrent haematuria or urinary tract infections, or refractory urinary retention; no wish for surgery as primary treatment).[17]
Patients may also benefit from behavioural and lifestyle modifications including reducing fluids at night and before travel, limiting caffeinated and alcoholic drinks, avoiding or modifying the timing of diuretics or medications that increase urinary retention, preventing or treating constipation, and use of techniques to help control bladder symptoms (e.g., bladder training, pelvic floor exercises).[17][18]
Consider a PDE-5 inhibitor for patients with BPH and erectile dysfunction, or as a second-line option.[17] Tadalafil is the only approved PDE-5 inhibitor for patients with comorbid BPH and erectile dysfunction. It may be considered for those showing incomplete response and/or those who cannot tolerate an alpha-blocker irrespective of comorbid erectile dysfunction.[17][18][44] An evaluation of data from eight systematic reviews demonstrated that PDE-5 inhibitors improve LUTS and erectile function with a negligible change in flow rate.[45] PDE-5 inhibitors in combination with alpha-blockers improved flow rate compared with alpha-blockers alone.[46]
[ ]
Evidence on disease progression and long-term efficacy and tolerability for PDE-5 inhibitors is lacking.[18][47]
Primary options
tadalafil: 5 mg orally once daily
anticholinergic agent + behavioural management programme
In general, offer medical therapy as first-line management for patients with bothersome, moderate to severe symptoms of BPH who do not require surgery (i.e., absence of complications attributed to BPH, such as renal insufficiency, bladder stones, recurrent haematuria or urinary tract infections, or refractory urinary retention; no wish for surgery as primary treatment).[17]
Patients may also benefit from behavioural and lifestyle modifications including reducing fluids at night and before travel, limiting caffeinated and alcoholic drinks, avoiding or modifying the timing of diuretics or medications that increase urinary retention, preventing or treating constipation, and use of techniques to help control bladder symptoms (e.g., bladder training, pelvic floor exercises).[17][18]
Anticholinergic therapy may be considered for men with BPH and predominantly bladder storage symptoms.[17][18] Anticholinergic agents (e.g., tolterodine, fesoterodine, oxybutynin, solifenacin) may improve symptoms of overactive bladder.[48][49][50]
[ ]
Anticholinergic-associated adverse events include dry eyes, dry mouth, constipation, micturition difficulties, nasopharyngitis, and dizziness.[18] Previous concerns over risk of worsening bladder retention appear to be unfounded.[17] An increased risk of dementia has been associated with anticholinergics.[51]
Primary options
tolterodine: 2 mg orally (immediate-release) twice daily; 4 mg orally (extended-release) once daily
OR
fesoterodine: 4-8 mg orally (extended-release) once daily
OR
oxybutynin: 5 mg orally (immediate-release) two to three times daily initially, increase gradually according to response, maximum 5 mg four times daily; 5-10 mg orally (extended-release) once daily, increase gradually according to response, maximum 30 mg/day
OR
solifenacin: 5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day
combination drug therapy
May be considered for patients with moderate or severe symptoms who are at risk of disease progression, and those who have inadequate symptom control or progression on monotherapy.[17]
A 5-alpha-reductase inhibitor in combination with an alpha-blocker can be considered for patients with larger prostates who experience symptom progression on monotherapy.[17][18][52][53] Combination therapy with a 5-alpha-reductase inhibitor and an alpha-blocker may be associated with sexual dysfunction, including erectile and ejaculatory dysfunction.[56] One systematic review reported that combination therapy with a 5-alpha-reductase inhibitor plus an alpha-blocker showed a greater than 4 point improvement in International Prostate Symptom Score, and was significantly better than monotherapy.[54] Treatment with tamsulosin plus dutasteride for 4 years appears to reduce the risk of clinical progression, acute urinary retention, and the need for BPH-related surgery.[55]
Men with BPH treated with an alpha-blocker in combination with a 5-alpha-reductase inhibitor may be at increased risk for heart failure compared with no medication use; nonselective alpha-blockers appear to be associated with a higher risk of heart failure than selective alpha-blockers.[38]
Anticholinergic therapy in combination with an alpha-blocker is suitable for men with predominantly bladder storage symptoms.[17][18][49] One meta-analysis demonstrated that alpha-blockers in combination with anticholinergic medication may improve symptoms without causing significant deterioration in voiding function.[57] A subsequent Cochrane review found that combination therapy with anticholinergics and alpha-blockers was associated with little or uncertain effects on urinary symptoms, although it may improve quality of life compared with anticholinergics alone.[58] Combination therapy likely increases adverse effects compared with placebo but not compared with alpha-blocker or anticholinergic monotherapy.[58]
Beta-3 adrenergic agonists (e.g., mirabegron, vibegron) may be offered in combination with an alpha-blocker to BPH patients with moderate to severe predominantly storage LUTS.[17][18] One randomised controlled trial showed that combination therapy with tamsulosin and mirabegron improved storage LUTS symptoms in men with BPH who have persistent symptoms despite tamsulosin monotherapy.[59] Beta-3 adrenergic agonists should be used with caution in older men and those with bladder outlet obstruction (post-void residuals greater than 250 mL).[20]
A PDE-5 inhibitor (e.g., tadalafil) plus an alpha-blocker may be considered for combination therapy, although evidence is limited..[17][18] Systematic reviews suggest that combination treatment with a PDE-5 inhibitor and an alpha-blocker is more effective than monotherapy for improving symptoms of BPH in men with or without erectile dysfunction, but the rate of adverse effects is higher.[46][60]
[ ]
According to one meta-analysis, younger men with lower BMI and severe urinary symptoms may benefit in particular from a PDE-5 inhibitor in combination with an alpha-blocker.[18][61] However, further studies are needed to confirm which patients gain most benefit from this combination.
A proprietary formulation of the 5-alpha-reductase inhibitor finasteride and the PDE-5 inhibitor tadalafil is available, which may be considered for men with larger prostates.[17] The Food and Drug Administration (FDA) has approved finasteride/tadalafil for the treatment of the signs and symptoms of BPH in men with an enlarged prostate. Phase 3 studies found that combination treatment with finasteride and tadalafil significantly improved LUTS and erectile and sexual function compared to treatment with finasteride and placebo.[62][63] Finasteride/tadalafil can be used when considering combination therapies, or if patients have intolerable adverse effects from 5-alpha-reductase inhibitor monotherapy, for a maximum duration of 26 weeks.
Primary options
terazosin: 1 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day given in 2 divided doses
or
doxazosin: 1 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 8 mg/day; 4 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 8 mg/day
or
alfuzosin: 10 mg orally once daily (extended-release)
or
tamsulosin: 0.4 mg orally once daily initially, increase gradually according to response, maximum 0.8 mg/day
or
silodosin: 8 mg orally once daily
-- AND --
finasteride: 5 mg orally once daily
or
dutasteride: 0.5 mg orally once daily
or
tadalafil: 5 mg orally once daily
or
tolterodine: 2 mg orally (immediate-release) twice daily; 4 mg orally (extended-release) once daily
or
fesoterodine: 4-8 mg orally (extended-release) once daily
or
oxybutynin: 5 mg orally (immediate-release) two to three times daily initially, increase gradually according to response, maximum 5 mg four times daily; 5-10 mg orally (extended-release) once daily, increase gradually according to response, maximum 30 mg/day
or
solifenacin: 5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day
OR
tamsulosin: 0.4 mg orally once daily initially, increase gradually according to response, maximum 0.8 mg/day
-- AND --
mirabegron: 25-50 mg once daily
or
vibegron: 75 mg orally once daily
OR
finasteride/tadalafil: 5 mg (finasteride)/5 mg (tadalafil) orally once daily
moderately invasive therapy: TURP, TUVP, laser enucleation or vaporisation (HoLEP, ThuLEP, PVP)
Refer patients to a urologist for surgery for lower urinary tract symptoms (LUTS)/BPH if: they have complications attributed to BPH, such as acute and/or chronic renal insufficiency, recurrent bladder stones, gross recurrent haematuria, recurrent urinary tract infections, or refractory urinary retention; or they have refractory responses to medication, are unwilling to use medication, or experience intolerable adverse effects with medication.[17]
A variety of procedures can be performed. The decision to select a specific procedure is shared between the patient and the urologist with respect to risk/benefit of each procedure, availability of equipment, clinician expertise, and patient comorbidities.[33] Prostate size and morphology play important roles in decision-making on treatment approach.[17] Patients on active anticoagulation are at lower risk with procedures associated with less bleeding such as laser enucleation or vaporisation.[17][18]
TURP and TUVP are more invasive and entail more risk than minimally invasive therapies, but can improve symptoms to a greater degree.
TURP is the standard surgical procedure for men with prostate sizes <80 g and bothersome LUTS due to BPH.[17][18] TURP is the historical standard against which all other surgical approaches are compared. The procedure can be performed with a spinal or epidural anaesthetic, or with a general anaesthetic. Classic TURP uses monopolar electrocautery; however, bipolar TURP has become a more common procedure, with similar functional outcomes and improved perioperative outcomes compared with monopolar TURP.[64][65]
[ ]
[Evidence B] Bipolar TURP reduces the risk of dilutional hyponatraemia, clot formation, and blood loss during longer procedures on larger glands. TURP provides excellent resolution of LUTS, but has an increased risk of bleeding compared with other procedures and also has a significant rate of unwanted sexual adverse effects (e.g., ejaculatory dysfunction).[18]
TUVP traditionally uses a standard monopolar electro-diathermy device as for TURP, but modification with a bipolar current enables use at lower temperatures for vaporisation. It can be considered for patients with small or average prostate size (<80 g).[17][18] Monopolar and bipolar TUVP are equally efficacious, but bipolar TUVP has a more favourable perioperative safety profile.[67] TUVP has reduced blood loss in contrast to TURP.[68]
Laser vaporisation may also be used to resect or ablate prostate tissue.
Photoselective vaporisation of the prostate (PVP) may be considered in patients with prostate size <80 g at higher risk of bleeding, such as those on anticoagulation, because of its haemostatic effect on prostate tissue.[17][18]
PVP uses a side-firing laser at a wavelength absorbed by haemoglobin. This results in tissue vaporisation and an underlying layer of coagulation providing good haemostasis; therefore, it is preferred in patients at higher risk of bleeding (e.g., patients on anticoagulants). Studies have shown similar outcomes, both beneficial and adverse, compared with TURP.[71] PVP may be more efficacious in glands <60 g as two cohort studies showed conversion to TURP in glands between 60 and 80 g.[72][73]
Clinicians should consider laser enucleation (holmium laser enucleation of the prostate [HoLEP] and thulium laser enucleation of the prostate [ThuLEP]), depending on their expertise with either technique, as prostate size-independent suitable options.[17][18][69]
PVP, HoLEP, or ThuLEP techniques have fewer bleeding complications when compared with TURP and appear to be comparable with respect to symptom improvement in short-term follow-up.[70][71][95][96][97][98][99]
moderately invasive therapy: TURP, TUVP, laser enucleation or vaporisation (HoLEP, ThuLEP, PVP), or aquablation
Refer patients to a urologist for surgery for lower urinary tract symptoms (LUTS)/BPH if: they have complications attributed to BPH, such as acute and/or chronic renal insufficiency, recurrent bladder stones, gross recurrent haematuria, recurrent urinary tract infections, or refractory urinary retention; or they have refractory responses to medication, are unwilling to use medication, or experience intolerable adverse effects with medication.[17]
A variety of procedures can be performed. The decision to select a specific procedure is shared between the patient and the urologist with respect to risk/benefit of each procedure, availability of equipment, clinician expertise, and patient comorbidities.[33] Prostate size and morphology play important roles in decision-making on treatment approach.[17] Patients on active anticoagulation are at lower risk with procedures associated with less bleeding such as laser enucleation or vaporisation.[17][18]
Moderately invasive procedures are transurethral resection of the prostate (TURP), transurethral vaporisation of the prostate (TUVP), laser enucleation or vaporisation, and aquablation. TURP and TUVP are more invasive and entail more risk than minimally invasive therapies, but can improve symptoms to a greater degree.
TURP is the standard surgical procedure for men with prostate sizes <80 g and bothersome lower urinary symptoms due to BPH.[17][18] TURP is the historical standard against which all other surgical approaches are compared. The procedure can be performed with a spinal or epidural anaesthetic, or with a general anaesthetic. Classic TURP uses monopolar electrocautery; however, bipolar TURP has become a more common procedure, with similar functional outcomes and improved perioperative outcomes compared with monopolar TURP.[64][65]
[ ]
[Evidence B] Bipolar TURP reduces the risk of dilutional hyponatraemia, clot formation, and blood loss during longer procedures on larger glands. TURP provides excellent resolution of LUTS, but has an increased risk of bleeding compared with other procedures and also has a significant rate of unwanted sexual adverse effects (e.g., ejaculatory dysfunction).[18]
TUVP traditionally uses a standard monopolar electro-diathermy device as for TURP, but modification with a bipolar current enables use at lower temperatures for vaporisation. It can be considered for patients with small or average prostate size (<80 g).[17][18] Monopolar and bipolar TUVP are equally efficacious, but bipolar TUVP has a more favourable perioperative safety profile.[67] TUVP has reduced blood loss in contrast to TURP.[68]
Laser vaporisation may also be used to resect or ablate prostate tissue.
Photoselective vaporisation of the prostate (PVP) may be considered in patients with prostate size <80 g at higher risk of bleeding, such as those on anticoagulation, because of its haemostatic effect on prostate tissue.[17][18]
PVP uses a side-firing laser at a wavelength absorbed by haemoglobin. This results in tissue vaporisation and an underlying layer of coagulation providing good haemostasis; therefore, it is preferred in patients at higher risk of bleeding (e.g., patients on anticoagulants). Studies have shown similar outcomes, both beneficial and adverse, compared with TURP.[71] PVP may be more efficacious in glands <60 g as two cohort studies showed conversion to TURP in glands between 60 and 80 g.[72][73]
Clinicians should consider laser enucleation (holmium laser enucleation of the prostate [HoLEP] and thulium laser enucleation of the prostate [ThuLEP]), depending on their expertise with either technique, as prostate size-independent suitable options.[17][18][69]
PVP, HoLEP, or ThuLEP techniques have fewer bleeding complications when compared with TURP and appear to be comparable with respect to symptom improvement in short-term follow-up.[70][71][95][96][97][98][99]
Aquablation uses a handheld robotic arm with targeted tissue destruction followed by electro-cautery for haemostasis. It may be offered as a treatment option to patients with a prostate volume of 30 to 80 g.[17][18] One randomised controlled trial in men with a 30 to 80 g prostate volume found symptom reduction and uroflow improvement to be durable and consistent at 5-year follow-up.[81] Studies have also been conducted into aquablation for prostates between 80 and 150 g, but long-term follow-up data remain limited. Aquablation is not a minimally invasive surgical procedure as it requires general anaesthesia.
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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