7.4.1 Drugs for voiding (obstructive) symptoms in men

General Notes

  • Watchful waiting may be preferable if urinary symptoms are not bothersome.
  • Alpha–blockers are the treatment of choice for benign prostatic hyperplasia and are likely to provide symptom relief in men with prostates of any size. Response to treatment should be reviewed after 6 weeks
  • 5 alpha-reductase inhibitors can .be used in combination with alpha-blockers. Consider offering this combination to men with bothersome moderate to severe lower urinary tract symptoms with a prostate estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml.

Alpha blockers

ChoiceDrugDosage
1st choice

Tamsulosin 400 micrograms M/R capsules

NB - tamsulosin tablets are expensive, prescribe capsules

Dose: 400 micrograms daily
2nd choiceAlfuzosin 2.5mg tablets; 10mg M/R tablets

Dose:
2.5mg 3 times daily, max 10mg daily;
elderly: initially 2.5mg twice daily;
M/R tablets, 10mg once daily

Prescribing Notes

  • Refer to NICE Guidance CG97, Lower Urinary Tract Symptoms.
  • Alpha–blockers are the treatment of choice for benign prostatic hyperplasia, and are likely to provide symptom relief in men with prostates of any size. Response to treatment should be reviewed after 6 weeks.
  • Consider offering an anticholinergic as well as an alpha blocker to men who still have storage symptoms after treatment with an alpha blocker alone (see 7.4.2 for formulary choices).

Cautions

  • Patients already prescribed doxazosin for hypertension should not be prescribed another alpha blocker such as tamsulosin.
  • Alpha–blockers reduce blood pressure, first doses may cause drowsiness and dizziness. Patients receiving antihypertensives may need lower doses and supervision.
  • Alpha-blockers should be avoided in patients with a history of postural hypotension and micturition syncope.
  • Caution is required in the elderly and in patients undergoing cataract surgery (risk of intra-operative floppy iris syndrome).

5 alpha-reductase inhibitors

ChoiceDrugDosage
1st choiceFinasteride 5mg tabletsDose: 5mg daily

Prescribing Notes

  • Refer to NICE Guidance CG97, Lower Urinary Tract Symptoms.
  • 5 alpha-reductase inhibitors can be used in combination with alpha-blockers. Consider offering this combination to men with bothersome moderate to severe lower urinary tract symptoms with a prostate estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml.
  • There is no significant difference between dutasteride and finasteride for symptom improvement or rate of adverse effects. Finasteride is therefore recommended as the first line option as it is more cost effective.
  • 5 alpha-reductase inhibitors cause a decrease in mean serum PSA levels by approximately 50% after 6 months of treatment. Patients should therefore have a new PSA baseline established after 6 months of treatment. It is recommended to monitor PSA values regularly thereafter.
  • Combodart® (tamsulosin / dutasteride combination tablet) should be reserved for patients with compliance problems where reducing the overall tablet burden would improve patient safety. It is more cost effective to prescribe the individual generic components separately.
  • Treatment with 5 alpha-reductase inhibitors should be reviewed after 6 months. Several months of treatment may be required before benefit is obtained and any observed benefit may be lost after 3–6 months if treatment is discontinued.

Caution

  • The MHRA has received rare reports of depression and suicidal thoughts in men taking finasteride 1mg (Propecia®) for male pattern hair loss. Depression is also associated with finasteride 5mg (Proscar®).