The patient has since
discontinued therapy and complains of worsening BPH/LUTS (AUA-SI score, 9) and
ED. What is the new treatment plan for this patient?
Decrease
tamsulosin dose to minimize sexual AEs
Consider
combination therapy with tadalafil
Consider
monotherapy with tadalafil
Encourage
the patient to take saw palmetto, per AUA guidelines
Although
tamsulosin AEs are dose dependent, the patient does not want to use this
therapy again. Tadalafil is contraindicated with α-blocker therapy in patients
with BPH, but PDE5
inhibitor monotherapy may resolve the patient's mild ED and the couple's
concerns about his diminished libido and ejaculatory dysfunction from the
α-blocker.
Discussion
When
tadalafil is prescribed for ED in a patient already taking an α-blocker, the
patient should be stable on the α-blocker therapy prior to starting the
tadalafil and tadalafil should be initiated at the lowest recommended dose. However,
tadalafil is not recommended for use in combination with α-blockers for the
treatment of BPH.
Treatment Plan
Switch
from combination therapy to daily tadalafil to improve concomitant BPH/LUTS and
ED symptoms.
Follow-up
The
patient returns for follow-up 3 months later. He reports that the couple's
"sex life is back to normal," and he is grateful "[he] won't
have to hold client meetings in the restroom, which is what it was coming
to!" The patient's AUA-SI score is back to 6.
