Medical Management for BPH: The Role of Combination Therapy

An underlying scientific rationale exists for combining α-adrenergic blockade and 5α-reductase inhibition for the treatment of lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH), given that their modes of action in managing LUTS secondary to BPH are different and complementary. Both α-blockers and 5α-reductase inhibitors (5-ARIs) provide sustainable reductions in symptom scores. Although both classes of agents have data to support delays in acute urinary retention (AUR) and the need for invasive BPH therapy, only the 5-ARIs reduce the long-term risks of both events. Current evidence suggests that initiation of combination therapy should be considered in men with prostatic enlargement, elevated prostate-specific antigen (PSA) level, LUTS, and moderate or severe bother. The Medical Therapy of Prostate Symptoms (MTOPS) study provided evidence that the prostate volume threshold for benefit of a 5-ARI, and therefore of combination therapy, is lower than previously thought (>25 cc). Cost effectiveness in this population has been demonstrated to increase in men with severe symptoms, although transurethral resection of the prostate (TURP) is probably more favourable in the long-term from a cost perspective. However, many men wish to avoid surgery, and for them, combination therapy offers significant benefits over monotherapy, especially over α-blocker therapy where no long-term reductions in the risk of AUR or surgery have been demonstrated.