When’s the Right Time to Prescribe Alpha Blockers & 5-Alpha Reductase Inhibitor Combination for BPH?

Benign prostatic hyperplasia (BPH) is a common complication that leads to lower urinary tract symptoms (LUTS), and even renal failure.¹ Lately, there has been a transition from surgery to medical management of BPH due to alpha-blockers (ABs) that treat LUTS and 5-alpha reductase inhibitors (5-ARIs) that reduce prostate volume.² Furthermore, an AB+5-ARI combination is recommended for moderate-to-severe symptoms, large prostates (>30 g or >40 g), and poor flow rates.³

For this purpose, the various BPH detection techniques include digital rectal exam (DRE), uroflowmetry, radiographic imaging, magnetic resonance imaging, abdominal ultrasound (AUS), transrectal ultrasound, etc.^1,4 However, a significant challenge in accurate detection is the absence of standardized criteria for categorizing prostate volume.⁵ For instance, one of the baseline predictors for increased BPH progression risk is prostate volume ≥30 g.^2,while multiple studies indicate prostate volume <40 mL as small volume BPH.⁵ Adding to this complexity, BPH detection is not absolutely accurate, for e.g., DRE is a poor predictor of actual prostate size, while AUS carries only ~65% accuracy.^4,6

Conclusion

There is a transition from surgical to medical management for BPH and an AB+5-ARI combination therapy is recommended for enlarged prostates.² Therefore, detecting the correct prostate size is a prerequisite in deciding the right time to prescribe an AB+5-ARI combination.

CTA: Let us listen to the expert Dr. V Surya Prakash and explore the AB+5-ARI combination for large-size prostates.

1. Dincer E, Ipek OM, Sarikaya Kayipmaz S, et al. Giant prostatic hyperplasia: Case presentation of the second largest prostate adenoma. AFJU. 2021;27:1–4.
2. Kim EH, Brockman JA, Andriole GL. The use of 5-alpha reductase inhibitors in the treatment of benign prostatic hyperplasia. Asian J Urol. 2018;5(1):28–32.
3. Sabnis RB, Mulawkar PM, Joshi RN. The Urological Society of India guidelines on management of benign prostatic hyperplasia/benign prostatic obstruction (Executive summary). Indian J Urol. 2021;37(3):210–213.
4. Dekalo S, Savin Z, Schreter E, et al. Novel ultrasound-based volume estimation of prostatic benign enlargement to improve decision-making on surgical approach. Ther Adv Urol. 2021;13:1756287221993301.
5. Xu J, Han B, Xia S, et al. Beyond size: A comprehensive overview of small-volume benign prostatic hyperplasia. Curr Urol. 2022;10–97.
6. Udeh EI, Dakum NK, Aderibigbe SA, et al. The utility of digital rectal examination in estimating prostate volume in a rural hospital setting. Niger J Surg. 2015;21(2):111–114.

LMRC CODE: GGI-CO-A1-AQS-300020632-BANNERS-J24-0654