Tools for Practice

#164 Alpha blockers for BPH-LUTS: Let it flow or still slow?

How effective are alpha-blockers in reducing lower urinary tract symptoms (LUTS) in men with benign prostatic hypertrophy (BPH)?

Alpha-blockers are effective as first line therapy for LUTS-BPHCompared to placebo, around 1 in 10 will have improved symptoms and/or avoid symptom progression while approximately 1 in 50 will experience hypotension or dizziness. Mainly indirect comparisons suggest doxazosin and terazosin may be slightly more effective but have increased risk of adverse events.  

CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

Join Now

Already a CFPCLearn Member? Log in

  • 15 systematic reviews of alpha-blockers in symptomatic BPH.1 
    • Versus placebo (26 Randomized Controlled Trials (RCTs)): Alpha-blockers:2 
      • Improved peak urinary flow (Qmax): 1.32 ml⁄s. 
      • Decreased symptoms [International Prostate Symptom Score (IPSS)]: -1.92. 
    • Network meta-analysis (124 RCTs)3 compared doxazosin, terazosinalfuzosin, and tamsulosin:  
      • Improved Qmax (ml/s): 1.951.211.07 and 1.07 respectively. 
      • Decreased IPSS by: -3.67, -3.37, -2.13, and -2.07 respectively. 
        • Doxazosin significantly better for both outcomes. 
      • Doxazosin and terazosin (non-uroselective): Significant increase in adverse events (dizziness and headache). 
  • Systematic review compares alpha-blockers to finasteride (alpha-reductase inhibitor). 
    • 23 RCTs (20,821 patients) finasteride:4 
      • Inferior to doxazosin and terazosin for Qmax and IPSS at one year. 
      • Non-inferior to tamsulosin. 
    • Finasteride and dutasteride similarly effective.5,6 
  • RCT (3,047 men) of placebo versus doxazosin, finasteride, or combination. Compared to placebo, doxazosin:7 
    • Reduced BPH symptom progression, Number Needed to Treat (NNT)=15 over four years. 
    • Increased hypotension (Number Needed to Harm (NNH)=58) and dizziness (NNH=48). 
  • Three pooled RCTs (955 patients):8 More men receiving alfuzosin (76%) reached point improvement on IPSS than placebo (62%), NNT=7. 
  • Guidelines recommend alpha-blockers as first line therapy for symptomatic BPH.9,10 
  • Clinically meaningful improvement of IPSS is ≥2-6, depending on baseline.11 
  • Transurethral resection12,13 of the prostate improves Qmax 10-11 ml/s and decreases IPSS 16.7. 
  • Alpha blockers associated with increased risk of falls (NNT=589) and fracture (NNT=1,667).14 
  • 2013 systematic review comparing alpha-blockers to combination therapy with alpha reductase inhibitors: Combination therapy effective for enlarged prostates and treatment for >1 year.15 

Latest Tools for Practice

#348 How to Slow the Flow III: Tranexamic acid for heavy menstrual bleeding (Free)

In premenopausal heavy menstrual bleeding due to benign etiology, does tranexamic acid (TXA) improve patient outcomes?
Read 0.25 credits available

#347 Chlorthali-D’OH!: What is the best thiazide diuretic for hypertension?

Which thiazide diuretic is best at reducing cardiovascular events in hypertension?
Read 0.25 credits available

#346 Stress Urinary Incontinence: Pelvic floor exercises or pessary? (Free)

How effective are pelvic floor exercises or pessaries for stress urinary incontinence?
Read 0.25 credits available

This content is certified for MainPro+ Credits, log in to access


  • Christina Korownyk MD CCFP
  • Mathieos Belayneh

1. Yuan J, Liu Y, Yang Z, et al. Curr Med Res Opin. 2013; 29:279-87.

2. Nickel JC, Sander S, Moon TD. Int J Clin Pract. 2008; 62:1547-59.

3. Yuan JQ, Mao C, Wong SY, et al. Medicine (Baltimore). 2015; 94:e974.

4. Tacklind J, Fink HA, MacDonald R, et al. Cochrane Database Syst Rev. 2010; 10:CD006015

5. Nickel JC, Gilling P, Tammela TL, et al. BJU Int. 2011; 108:388-94.

6. Kaplan SA. J Urol. 2012; 187:584-5.

7. McConnell JD, Roehrborn CG, Bautista OM, et al. N Engl J Med. 2003; 349:2387-98.

8. Roehrborn CG, Van Kerrebroeck P, Nordling J. BJU Int. 2003; 92:257-61.

9. McVary KT, Roehrborn CG, Avins AL, et al. J Urol. 2011; 185(5):1793-803.

10. Nickel, JC, Méndez-Probst CE, Whelan TF, et al. Can Urol Assoc J. 2010 Oct; 4(5):310-6.

11. Barry MJ, Williford WO, Chang YC, et al. J Urol. 1995; 154:1770.

12. Milonas D, Verikaite J, Jievaltas M. Cent European J Urol. 2015; 68:169-74.

13. Reich O, Gratzke C, Bachmann A, et al. J Urol. 2008; 180:246-9.

14. Welk B, McArthur E, Fraser LA, et al. BMJ. 2015; 351:h5398.

15. Füllhase C, Chapple C, Cornu JN, et al. Eur Urol. 2013; 64:228-43.

Authors do not have any conflicts to disclose.