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Enlarged Prostate Special Report

Two-Drug Options for BPH

In the 1980s, state-of-the-art treatment for men with benign prostatic hyperplasia (BPH) who experienced symptoms consisted of a transurethral prostatectomy. Beginning in the 1990s, medical treatment with either an alpha blocker to relax the smooth muscle in the prostate or a 5-alpha reductase inhibitor to shrink the prostate (or the two combined) became state-of-the art treatment. But today, advances in our understanding of BPH are helping doctors tailor therapy to a man's specific lower urinary tract symptoms and their causes. Often, that tailored treatment requires more than one medication, and one of those medications may not be a traditional BPH drug.

Recently researchers have expanded their study of multidrug therapy for BPH to include medications for overactive bladder and erectile dysfunction (ED).

Overactive bladder drugs for BPH. Some of the symptoms associated with BPH, such as urinary urgency and frequency and frequent nighttime urination, may sometimes be the consequence of an overactive bladder. As a result, doctors have tried a combination treatment that involves the use of tolterodine (Detrol), a medication for overactive bladder, in combination with an alpha-blocker like tamsulosin (Flomax). Like alpha-blockers, drugs used to treat overactive bladder relax the muscles that trigger bladder emptying, but they do so by a different mechanism.

In the Tolterodine and Tamsulosin for Treatment of Men With Lower Urinary Tract Symptoms and Overactive Bladder (TIMES) study, 879 men with BPH and lower urinary tract symptoms that included overactive bladder were randomly assigned to receive a placebo, Detrol, Flomax, or a combination of Detrol and Flomax. After three months, men taking the combination treatment were significantly more likely to experience an improvement in symptoms than those in the placebo group (80% versus 62%). However, taking Flomax or Detrol alone was not significantly more effective than a placebo.

These findings suggest that the addition of an overactive bladder drug is a good option when an alpha-blocker is not enough to control symptoms in men with both BPH and overactive bladder. Researchers aren't sure why the drug combination worked better than either drug alone. It's possible that some men were simply resistant to one of the two drugs.

ED drugs for BPH. A link between lower urinary tract symptoms and erectile dysfunction appears to exist. For example, in three large, randomized trials, men with BPH and ED who were treated for ED with sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra) also experienced improvements in their lower urinary tract symptoms and quality of life. None of the ED drugs improved urinary flow rate, suggesting that combining them with alpha-blockers might be an effective approach.

In a recent study, researchers randomly assigned 62 men with BPH and ED to take alfuzosin (Uroxatral), Viagra, or a combination of the two. After 12 weeks, men in the combination group experienced greater improvements in BPH symptoms than those taking either drug alone. Those on the combination also reported better sexual function.

The main concern with this approach is the possibility of lowering blood pressure too much. In a small study of 37 men with BPH and ED, the combination of the ED drug Levitra and the alpha-blocker doxazosin (Cardura) reduced standing systolic blood pressure by an average of 6 mm Hg, but this blood pressure drop was not associated with symptoms such as dizziness or fainting. Nevertheless, to reduce the risk of this side effect, doctors recommend taking the drugs separately -- at least four hours apart.

Posted in Enlarged Prostate on July 27, 2010

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