Editing Benign prostatic hyperplasia (section)

=== Medications ===
The two main medication classes for BPH management are [[alpha blocker]]s and [[5α-reductase inhibitor]]s.<ref>{{cite journal | vauthors = Silva J, Silva CM, Cruz F | title = Current medical treatment of lower urinary tract symptoms/BPH: do we have a standard? | journal = Current Opinion in Urology | volume = 24 | issue = 1 | pages = 21–28 | date = January 2014 | pmid = 24231531 | doi = 10.1097/mou.0000000000000007 | s2cid = 40954757 }}</ref>

==== Alpha-blockers ====
[[Alpha-1 blocker|Selective α<sub>1</sub>-blockers]] are the most common choice for initial therapy.<ref name="Roehrborn2007">{{cite journal | vauthors = Roehrborn CG, Nuckolls JG, Wei JT, Steers W | title = The benign prostatic hyperplasia registry and patient survey: study design, methods, and patient baseline characteristics | journal = BJU International | volume = 100 | issue = 4 | pages = 813–819 | date = October 2007 | pmid = 17822462 | doi = 10.1111/j.1464-410X.2007.07061.x | hdl-access = free | s2cid = 21001077 | collaboration = BPH Registry and Patient Survey Steering Committee | hdl = 2027.42/73286 }}</ref><ref name="Black2006">{{cite journal | vauthors = Black L, Naslund MJ, Gilbert TD, Davis EA, Ollendorf DA | title = An examination of treatment patterns and costs of care among patients with benign prostatic hyperplasia | journal = The American Journal of Managed Care | volume = 12 | issue = 4 Suppl | pages = S99–S110 | date = March 2006 | pmid = 16551208 | url = http://www.ajmc.com/pubMed.php?pii=3096 }}</ref><ref name="Hutchison2007">{{cite journal | vauthors = Hutchison A, Farmer R, Verhamme K, Berges R, Navarrete RV | title = The efficacy of drugs for the treatment of LUTS/BPH, a study in 6 European countries | journal = European Urology | volume = 51 | issue = 1 | pages = 207–15; discussion 215–6 | date = January 2007 | pmid = 16846678 | doi = 10.1016/j.eururo.2006.06.012 }}</ref> They include [[alfuzosin]],<ref name="MacDonald2005">{{cite journal | vauthors = MacDonald R, Wilt TJ | title = Alfuzosin for treatment of lower urinary tract symptoms compatible with benign prostatic hyperplasia: a systematic review of efficacy and adverse effects | journal = Urology | volume = 66 | issue = 4 | pages = 780–788 | date = October 2005 | pmid = 16230138 | doi = 10.1016/j.urology.2005.05.001 }}</ref><ref name="Roehrborn2001">{{cite journal | vauthors = Roehrborn CG | title = Efficacy and safety of once-daily alfuzosin in the treatment of lower urinary tract symptoms and clinical benign prostatic hyperplasia: a randomized, placebo-controlled trial | journal = Urology | volume = 58 | issue = 6 | pages = 953–959 | date = December 2001 | pmid = 11744466 | doi = 10.1016/S0090-4295(01)01448-0 }}</ref> [[doxazosin]],<ref name="MacDonald2004">{{cite journal | vauthors = MacDonald R, Wilt TJ, Howe RW | title = Doxazosin for treating lower urinary tract symptoms compatible with benign prostatic obstruction: a systematic review of efficacy and adverse effects | journal = BJU International | volume = 94 | issue = 9 | pages = 1263–1270 | date = December 2004 | pmid = 15610102 | doi = 10.1111/j.1464-410X.2004.05154.x | s2cid = 6640867 | doi-access = free }}</ref> [[silodosin]], [[tamsulosin]], [[terazosin]], and [[naftopidil]].<ref name="Hwang_2018" /> They have a small to moderate benefit at improving symptoms.<ref name="Wilt_2003" /><ref name="Hwang_2018" /><ref name="Djavan1999">{{cite journal | vauthors = Djavan B, Marberger M | title = A meta-analysis on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction | journal = European Urology | volume = 36 | issue = 1 | pages = 1–13 | year = 1999 | pmid = 10364649 | doi = 10.1159/000019919 | s2cid = 73366414 }}</ref> Selective alpha-1 blockers are similar in effectiveness but have slightly different side effect profiles.<ref name="Wilt_2003">{{cite journal | vauthors = Wilt TJ, Mac Donald R, Rutks I | title = Tamsulosin for benign prostatic hyperplasia | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD002081 | date = 2003 | pmid = 12535426 | doi = 10.1002/14651858.CD002081 | veditors = Wilt T }}</ref><ref name="Hwang_2018" /><ref name="Djavan1999" /> Alpha blockers relax smooth muscle in the prostate and the bladder neck, thus decreasing the blockage of urine flow. Common side effects of alpha-blockers include [[orthostatic hypotension]] (a head rush or dizzy spell when standing up or stretching), [[ejaculation]] changes, [[erectile dysfunction]],<ref>{{cite journal | vauthors = Santillo VM, Lowe FC | title = Treatment of benign prostatic hyperplasia in patients with cardiovascular disease | journal = Drugs & Aging | volume = 23 | issue = 10 | pages = 795–805 | year = 2006 | pmid = 17067183 | doi = 10.2165/00002512-200623100-00003 | s2cid = 24428368 }}</ref> headaches, nasal congestion, and weakness. For men with [[Lower urinary tract symptoms|LUTS]] due to an enlarged prostate, the effects of naftopidil, tamsulosin, and silodosin on urinary symptoms and quality of life may be similar.<ref name="Hwang_2018" /> Naftopidil and tamsulosin may have similar levels of unwanted sexual side effects but fewer unwanted side effects than silodosin.<ref name="Hwang_2018" />

Tamsulosin and silodosin are selective α1 receptor blockers that preferentially bind to the α1A receptor in the prostate instead of the α1B receptor in the blood vessels. Less-selective α1 receptor blockers such as terazosin and doxazosin may lower blood pressure. The older, less selective α1-adrenergic blocker prazosin is not a first-line choice for either [[hypertension|high blood pressure]] or prostatic hyperplasia; it is a choice for patients who present with both problems at the same time. The older, broadly non-selective alpha-blocker medications such as [[phenoxybenzamine]] are not recommended for control of BPH.<ref name="pmid12853821">{{cite journal | title = AUA guideline on management of benign prostatic hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations | journal = The Journal of Urology | volume = 170 | issue = 2 Pt 1 | pages = 530–547 | date = August 2003 | pmid = 12853821 | doi = 10.1097/01.ju.0000078083.38675.79 | author1 = AUA Practice Guidelines Committee }}</ref> Non-selective alpha-blockers such as terazosin and doxazosin may also require slow dose adjustments as they can lower blood pressure and cause [[syncope (medicine)|syncope]] (fainting) if the response to the medication is too strong.

==== 5α-reductase inhibitors ====

The 5α-reductase inhibitors [[finasteride]] and [[dutasteride]] may also be used in people with BPH.<ref name="Blankstein2016">{{cite journal | vauthors = Blankstein U, Van Asseldonk B, Elterman DS | title = BPH update: medical versus interventional management | journal = The Canadian Journal of Urology | volume = 23 | issue = Suppl 1 | pages = 10–15 | date = February 2016 | pmid = 26924590 | url = http://www.canjurol.com/html/free-articles/V23I1S1F-07_DrElterman.pdf | url-status = live | archive-url = https://web.archive.org/web/20160807134146/http://www.canjurol.com/html/free-articles/V23I1S1F-07_DrElterman.pdf | archive-date = 7 August 2016 }}</ref> These medications inhibit the [[5α-reductase]] enzyme, which, in turn, inhibits the production of [[Dihydrotestosterone|DHT]], a hormone responsible for enlarging the prostate. Effects may take longer to appear than alpha blockers, but they persist for many years.<ref name="Roehrborn2004">{{cite journal | vauthors = Roehrborn CG, Bruskewitz R, Nickel JC, McConnell JD, Saltzman B, Gittelman MC, Malek GH, Gottesman JE, Suryawanshi S, Drisko J, Meehan A, Waldstreicher J | title = Sustained decrease in incidence of acute urinary retention and surgery with finasteride for 6 years in men with benign prostatic hyperplasia | journal = The Journal of Urology | volume = 171 | issue = 3 | pages = 1194–1198 | date = March 2004 | pmid = 14767299 | doi = 10.1097/01.ju.0000112918.74410.94 | collaboration = Proscar Long-Term Efficacy Safety Study Group }}</ref> When used together with alpha-blockers, no benefit was reported in short-term trials, but in a longer-term study (3–4 years) there was a greater reduction in BPH progression to acute urinary retention and surgery than with either agent alone, especially in people with more severe symptoms and larger prostates.<ref>{{cite journal | vauthors = Roehrborn CG, Barkin J, Tubaro A, Emberton M, Wilson TH, Brotherton BJ, Castro R | title = Influence of baseline variables on changes in International Prostate Symptom Score after combined therapy with dutasteride plus tamsulosin or either monotherapy in patients with benign prostatic hyperplasia and lower urinary tract symptoms: 4-year results of the CombAT study | journal = BJU International | volume = 113 | issue = 4 | pages = 623–635 | date = April 2014 | pmid = 24127818 | doi = 10.1111/bju.12500 | s2cid = 38243275 }}</ref><ref name="ReferenceB">{{cite journal | vauthors = Greco KA, McVary KT | title = The role of combination medical therapy in benign prostatic hyperplasia | journal = International Journal of Impotence Research | volume = 20  | issue = Suppl 3 | pages = S33–S43 | date = December 2008 | pmid = 19002123 | doi = 10.1038/ijir.2008.51 | doi-access = free }}</ref><ref name="pmid16406915">{{cite journal | vauthors = Kaplan SA, McConnell JD, Roehrborn CG, Meehan AG, Lee MW, Noble WR, Kusek JW, Nyberg LM | title = Combination therapy with doxazosin and finasteride for benign prostatic hyperplasia in patients with lower urinary tract symptoms and a baseline total prostate volume of 25 ml or greater | journal = The Journal of Urology | volume = 175 | issue = 1 | pages = 217–20; discussion 220–1 | date = January 2006 | pmid = 16406915 | doi = 10.1016/S0022-5347(05)00041-8 | collaboration = Medical Therapy of Prostatic Symptoms (MTOPS) Research Group }}</ref> Other trials have confirmed reductions in symptoms, within 6 months in one trial, an effect that was maintained after withdrawal of the alpha blocker.<ref name="ReferenceB" /><ref>{{cite journal | vauthors = Barkin J, Guimarães M, Jacobi G, Pushkar D, Taylor S, van Vierssen Trip OB | title = Alpha-blocker therapy can be withdrawn in the majority of men following initial combination therapy with the dual 5alpha-reductase inhibitor dutasteride | journal = European Urology | volume = 44 | issue = 4 | pages = 461–466 | date = October 2003 | pmid = 14499682 | doi = 10.1016/s0302-2838(03)00367-1 }}</ref> Side effects include decreased [[libido]] and ejaculatory or erectile dysfunction.<ref name = Gormley>{{cite journal | vauthors = Gormley GJ, Stoner E, Bruskewitz RC, Imperato-McGinley J, Walsh PC, McConnell JD, Andriole GL, Geller J, Bracken BR, Tenover JS | title = The effect of finasteride in men with benign prostatic hyperplasia. The Finasteride Study Group | journal = The New England Journal of Medicine | volume = 327 | issue = 17 | pages = 1185–1191 | date = October 1992 | pmid = 1383816 | doi = 10.1056/NEJM199210223271701 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Gacci M, Ficarra V, Sebastianelli A, Corona G, Serni S, Shariat SF, Maggi M, Zattoni F, Carini M, Novara G | title = Impact of medical treatments for male lower urinary tract symptoms due to benign prostatic hyperplasia on ejaculatory function: a systematic review and meta-analysis | journal = The Journal of Sexual Medicine | volume = 11 | issue = 6 | pages = 1554–1566 | date = June 2014 | pmid = 24708055 | doi = 10.1111/jsm.12525 }}</ref> The 5α-reductase inhibitors are contraindicated in pregnant women because of their [[teratogenicity]] due to interference with fetal testosterone metabolism, and as a precaution, pregnant women should not handle crushed or broken tablets.<ref>{{cite web | vauthors = Deters L |title = Benign Prostatic Hypertrophy Treatment & Management |url = http://emedicine.medscape.com/article/437359-treatment |website = Medscape |access-date = 14 November 2015 |url-status = live |archive-url = https://web.archive.org/web/20151030062812/http://emedicine.medscape.com/article/437359-treatment |archive-date = 30 October 2015}}</ref>
[[File:NHS-medicines-effectiveness.png|none|thumb|650x650px|The effectiveness of alpha-blockers and 5-ARIs, and a combination of the two, versus placebo pills, in improving symptoms of an enlarged prostate.<ref name="McConnell_2003">{{cite journal | vauthors = McConnell JD, Roehrborn CG, Bautista OM, Andriole GL, Dixon CM, Kusek JW, Lepor H, McVary KT, Nyberg LM, Clarke HS, Crawford ED, Diokno A, Foley JP, Foster HE, Jacobs SC, Kaplan SA, Kreder KJ, Lieber MM, Lucia MS, Miller GJ, Menon M, Milam DF, Ramsdell JW, Schenkman NS, Slawin KM, Smith JA | title = The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia | journal = The New England Journal of Medicine | volume = 349 | issue = 25 | pages = 2387–2398 | date = December 2003 | pmid = 14681504 | doi = 10.1056/NEJMoa030656 }}</ref><ref name="Roehrborn_2010">{{cite journal | vauthors = Roehrborn CG, Siami P, Barkin J, Damião R, Major-Walker K, Nandy I, Morrill BB, Gagnier RP, Montorsi F | title = 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 | journal = European Urology | volume = 57 | issue = 1 | pages = 123–131 | date = January 2010 | pmid = 19825505 | doi = 10.1016/j.eururo.2009.09.035 }}</ref><ref name="Kaplan_2006">{{cite journal | vauthors = Kaplan SA, Roehrborn CG, Rovner ES, Carlsson M, Bavendam T, Guan Z | title = Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder: a randomized controlled trial | journal = JAMA | volume = 296 | issue = 19 | pages = 2319–2328 | date = November 2006 | pmid = 17105794 | doi = 10.1001/jama.296.19.2319 }}</ref>

Graphic from NHS England.<ref name="www.england.nhs.uk" />]]
[[File:NHS-medicines-sideeffects.png|none|thumb|676x676px|The frequency of side effects from alpha-blockers and 5-ARIs.<ref name="McConnell_2003" /><ref name="Roehrborn_2010" /><ref name="Kaplan_2006" /><ref>{{cite journal | vauthors = van Dijk MM, de la Rosette JJ, Michel MC | title = Effects of alpha(1)-adrenoceptor antagonists on male sexual function | journal = Drugs | volume = 66 | issue = 3 | pages = 287–301 | date = 2006-02-01 | pmid = 16526818 | doi = 10.2165/00003495-200666030-00002 }}</ref><ref>{{cite journal | vauthors = Descazeaud A, de La Taille A, Giuliano F, Desgrandchamps F, Doridot G | title = [Negative effects on sexual function of medications for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia] | journal = Progres en Urologie | volume = 25 | issue = 3 | pages = 115–127 | date = March 2015 | pmid = 25605342 | doi = 10.1016/j.purol.2014.12.003 }}</ref><ref>{{Cite web |date=2010-05-23 |title=Evidence {{!}} Lower urinary tract symptoms in men: management {{!}} Guidance {{!}} NICE |url=https://www.nice.org.uk/guidance/cg97/evidence |access-date=2024-09-08 |website=www.nice.org.uk}}</ref>

Graphic from NHS England.<ref name="www.england.nhs.uk" />]]

====Phosphodiesterase inhibitors (PDE)====

A 2018 Cochrane review of studies on men over 60 with moderate to severe [[lower urinary tract symptoms]] analyzed the impacts of [[phosphodiesterase inhibitor]]s (PDE) in comparison to other drugs.<ref>{{cite journal | vauthors = Pattanaik S, Mavuduru RS, Panda A, Mathew JL, Agarwal MM, Hwang EC, Lyon JA, Singh SK, Mandal AK | title = Phosphodiesterase inhibitors for lower urinary tract symptoms consistent with benign prostatic hyperplasia | journal = The Cochrane Database of Systematic Reviews | volume = 2018 | issue = 11 | pages = CD010060 | date = November 2018 | pmid = 30480763 | pmc = 6517182 | doi = 10.1002/14651858.CD010060.pub2 | collaboration = Cochrane Urology Group }}</ref> These drugs may improve urinary symptoms slightly and reduce urinary bother but may also cause more side effects than placebo. The evidence in this review found that there is probably no difference between PDE and [[alpha blocker]]s, however when used in combination they may provide a greater improvement in symptoms (with more side effects). PDE also likely improves symptoms when used with [[5-alpha reductase inhibitors]].

Several phosphodiesterase-5 inhibitors are also effective but may require multiple doses daily to maintain adequate urine flow.<ref>{{cite journal | vauthors = Wang Y, Bao Y, Liu J, Duan L, Cui Y | title = Tadalafil 5 mg Once Daily Improves Lower Urinary Tract Symptoms and Erectile Dysfunction: A Systematic Review and Meta-analysis | journal = Lower Urinary Tract Symptoms | volume = 10 | issue = 1 | pages = 84–92 | date = January 2018 | pmid = 29341503 | doi = 10.1111/luts.12144 | s2cid = 23929021 }}</ref><ref name="Pattanaik CD010060">{{cite journal | vauthors = Pattanaik S, Mavuduru RS, Panda A, Mathew JL, Agarwal MM, Hwang EC, Lyon JA, Singh SK, Mandal AK | title = Phosphodiesterase inhibitors for lower urinary tract symptoms consistent with benign prostatic hyperplasia | journal = The Cochrane Database of Systematic Reviews | volume = 2018 | issue = 11 | pages = CD010060 | date = November 2018 | pmid = 30480763 | pmc = 6517182 | doi = 10.1002/14651858.CD010060.pub2 }}</ref> [[Tadalafil]], a phosphodiesterase-5 inhibitor, was considered then rejected by NICE in the UK for the treatment of symptoms associated with BPH.<ref name="guidance.nice.org.uk">{{cite web |title = Hyperplasia (benign prostatic) – tadalafil (terminated appraisal) (TA273) |url = http://guidance.nice.org.uk/TA273 |work = National Institute for Health and Clinical Excellence (NICE) |date = 23 January 2013 |access-date = 27 January 2013 |url-status = live |archive-url = https://web.archive.org/web/20130224050938/http://guidance.nice.org.uk/TA273 |archive-date = 24 February 2013}}</ref> In 2011, the U.S. Food and Drug Administration approved tadalafil to treat the signs and symptoms of benign prostatic hyperplasia, and for the treatment of BPH and erectile dysfunction (ED), when the conditions occur simultaneously.<ref name="fda.gov">{{cite web |title = FDA approves Cialis to treat benign prostatic hyperplasia |url = https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm274642.htm |work = U.S. Food and Drug Administration (FDA) |access-date = 7 May 2013 |url-status = dead |archive-url = https://web.archive.org/web/20170118091151/https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm274642.htm |archive-date = 18 January 2017}}</ref>

==== Others ====

[[Antimuscarinic]]s such as [[tolterodine]] may also be used, especially in combination with alpha-blockers.<ref name="Kaplan2006">{{cite journal | vauthors = Kaplan SA, Roehrborn CG, Rovner ES, Carlsson M, Bavendam T, Guan Z | title = Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder: a randomized controlled trial | journal = JAMA | volume = 296 | issue = 19 | pages = 2319–2328 | date = November 2006 | pmid = 17105794 | doi = 10.1001/jama.296.19.2319 | doi-access = free }}</ref> They act by decreasing [[acetylcholine]] effects on the smooth muscle of the [[bladder]], thus helping control symptoms of an [[overactive bladder]].<ref>{{cite journal | vauthors = Abrams P, Andersson KE | title = Muscarinic receptor antagonists for overactive bladder | journal = BJU International | volume = 100 | issue = 5 | pages = 987–1006 | date = November 2007 | pmid = 17922784 | doi = 10.1111/j.1464-410x.2007.07205.x | s2cid = 30983780 | doi-access = free }}</ref>