American Family Physician - Medical treatment of benign prostatic hyperplasia
Clinical Question
What is the best medical therapy for benign prostatic hyperplasia (BPH)?
Evidence-Based Answer
Although alpha blockers and 5-alpha reductase inhibitors each reduce BPH symptoms more than placebo (Strength of Recommendation [SOR]: A), alpha blockers are more effective than 5-alpha reductase inhibitors. (SOR: B). Phytotherapy (herbal treatment) has potential but unproven benefit in BPH. (SOR: B).
Evidence Summary
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In a Cochrane systematic review of 14 randomized controlled trials (RCTs) with 4,122 patients, the alpha blocker tamsulosin (Flomax) demonstrated dose-dependent superiority in symptom relief over placebo. There was a 12 percent improvement in the American Urologic Association (AUA) symptom index (a 35-point symptom score) for 0.4 mg and 16 percent improvement for 0.8 mg. In general, a 10 to 20 percent improvement in symptom score is the minimum that is considered to be clinically significant. There were no significant differences in symptom relief between tamsulosin and other alpha blockers. (1)
Another Cochrane systematic review of 17 RCTs with 5,151 patients found that the alpha blocker terazosin (Hytrin) was more effective than placebo in reducing symptoms. Using a 27-point symptom score, the pooled mean improvement was 37 percent for terazosin versus 15 percent for placebo. (2) A single RCT of 1,229 patients favored terazosin over the 5-alpha reductase inhibitor finasteride (Proscar) and placebo in symptom reduction at one-year follow-up (17, 9, and 7 percent improvement in AUA symptom score, respectively). (3)
Another review found that finasteride and dutasteride (Avodart) were slightly more effective than placebo at symptom reduction (4 and 6 percent improvement in AUA symptom score, respectively). In head-to-head trials, alpha blockers were slightly more effective than 5-alpha reductase inhibitors in symptom score reduction and improving urinary flow rates. (4) One RCT of 3,047 men, which examined duration of benefit, showed that doxazosin (Cardura) had improved symptom control at one year (6 percent improvement in AUA symptom score; P
