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Urology/Which Alpha 1-blocker should a patient begin to take?


QUESTION: A patient is 50s and has a moderate enlarged prostate, about 5x6 cm. The cystoscopy displayed his bladder outlet has obstruction. He also has chronic prostate symptoms but doctors could not determine it is bacteria or none bacteria because the urine culture is negative. The patient also has bladder spasms pain after urinating.  The patient did not take any Alpha blocker medications before. Different urologists have prescribed the different Alpha 1-blocker medications Doxazosin, Rapaflo, Alfuzosin and Flomax. There is another one Terazosin in the market. Are there any guidelines or rules to select the alpha 1-blocker as starting the drug treatment and which one the patient should begin to take or try first? Thank you for your answer.

ANSWER: Randy,
Alpha blockers all use similar mechanisms but the newer 3rd generation like Rapaflow work at a faster rate when first taken but have more of a potential for retrograde ejaculation. In addition they are also very expensive as a cash pay drug and have a higher tier on the insurance approval listing. This means if you are not concerned with the fluid of the ejaculation part of an orgasm and you have no financial burden then Rapaflow is great. Now the second generation Uroxatrol is generic, relatively accessible to all insurance carrier plans and less incidents of retrograde ejaculation but still highly probable. The first generation like Flomax (tamulosin) and Hytrin (terazosin) have more of a blood pressure reducing capability and in-turn cause dizziness when going from sitting to standing. Now the one difference I find for Rapaflow than the others is the alternative uses like severe ureteral spasms from kidney stones or epididymal spasms post vasectomy pain the drug is needed to work quickly to resolve severe discomfort. No patient wants to wait 2-3 days of discomfort when a different drug can work in as little as 6-8 hours. In addition I prefer Rapaflow for patients with hydronephrosis as a result of BPH restriction or obstruction while catheterized because the drain can be removed sooner if the drug is working well. See its not as simple as take a generic or name brand. Most patients I think a generic cheap drug for simple BPH is best.

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QUESTION: Thank you for your quick answer. One Alpha adrenergic blocking agent may interact with other Alpha adrenergic blocking agent. Is there any potential problem or what should the patient do if he wants to change the Alpha-1 blocker medication such as downgrade from the third generation Rapaflow to the second even first generation drug such as Flomax, Cardura etc, or there is no problem at all but just simply stop the current Alpha-1 blocker medication and then try the different one?

One thing I failed to mention is if there was a clean urine culture then there obviously is no bacterial disease present to warrant antibiotic treatment but there may in fact be an inflammatory prostatitis present. Mixing of alpha blockers for the purpose of BPH is not a common practice and has a potential for hypotension therefore a single alpha blocker is more than sufficient. You may discontinue one and start an other with a day off in between. Now we should discuss why the alpha blockers are not working but the cystoscopy revealed BOO.
The prostate has two forms of obstruction, the most common is smooth muscle hypertrophy, the second is adenomas hyperplasia.

Patients with BOO are usually prescribed an alpha 1 agonist and see if the patients symptom score improves with the addition of a flow rate to cross reference the findings. If no improvement then there is a multitude of invasive options such as TURP, (resectioning) PVP,(laser TURP) TUNA,(needle ablation) TUMT (microwave therapy) and the non invasive 5 alpha reductase inhibitor (Proscar or Avodart). The 5 alpha reductase inhibitor will need a minimum of 6 to 9 months to see any improvement in flow. The resectioning and laser vaporization are both 1 time operating room procedures with instant results after swelling is reduced. The microwave and needle ablation have prolonged catheterization time after the procedure due to significant swelling and therefore results are seen in a few weeks and improve as time goes on if it works at all. There is a high failure rate of microwave and TUNA therefore at my location we never use it. Our preference is the Green Light Laser system (PVP). Hopefully this has answered your question.  


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Thomas A Suppe RDMS CLT


Invervential urologic radiology , urologic laser surgery, cryotherapy of the prostate and kidney, extracorporal shockwave lithotripsy, holmium laser lithotripsy, urodynamics (video-non video),male infertility, erectile dysfunction, Peyronies disease, hypogonadism ,kidney stones, prostate cancer detection, BPH, voiding dysfunction, bladder cancer and continent diversions.


For the past 20 years performing intervential and diagnostic uro-radiology for a multitude of urologic surgeons from New York, New Jersey, Lousianna and Texas. Founder of DMS medical LLC introducing the Texas Medical Center to the first high power Green Light laser for the treatment of BPH just after its release by the FDA from Laserscope and its sucessful trials at the Mayo Clinc.

American Registery of Diagnostic Medical Sonographers (ARDMS), American Urologic Assocoation (AUA), American Medical Systems (AMS) Laserscope,Oncura, Allergan and Auxilliam pharmaceuticals.

Comprehention of Urologic Ultrasonography for the Resident Physician (Journal of Urology 2012), Author of the syllabus for the uro-radiology residency course at The Scott Dept of Urology at Baylor College of Medicine Houston Texas (2010 to present). Past Clinical Studies: Principal radiology investigator Allergan Inc for "The treatment of BPH with intra-prostatic injections of Botox" with Larry I Lipshultz MD 2011-2012, principal radiology investigator for Allergan Inc for "The treatment of Peyronies disease by intra-lesional penile injections of Botox" with Mohit Khera MD MBA MPH (2011-2012). Current studies: Principal investigator of "Blood pressure risk factors of intra cavernosal injections of Trimix and PGE1 during Penile Duplex's.

BS from Ramapo College of NJ, Registered diagnostic medical sonographer with the ARDMS, 2 year fellowship of Uro-Radiology and intervential sonography at Baylor College of Medicine Houston TX, laser safty officer in state of Texas and certified in KTP, Holmium and Lithium Tri-boride laser systems from Laserscope San Jose, California and American Medical Systems Minnatonka Minnasota, trained and certified by Oncura Inc Isreal in ultrasound guided argon cryotherapy of the prostate and kidney.

Awards and Honors
Honorary instructor of GU ultrasound course 2012 international meeting of the American Urologic Association. Author of the the AUA course for "Ultrasonography of the Testes and Scrotum" 2012.

Past/Present Clients
Baylor College of Medicine (BCM) Lousianna State University (LSU), LSU Medical Center Shreeveport LA, The Methodist Hospital Houston Texas, St Lukes Episcopal Hospital Houston Texas, Memorial Herman Health Systems Houston Texas, Palestine RMC Texas, Doctors Regional Hospital Corpus Christi Texas, Valverde Regional Medical Center DelRio Texas, Current instructor/technologist for two internationally recognized urologists : Larry I Lipshultz MD and Mohit Khera MD, MBA, MPH at Baylor College of Medicine. I served as intervential sonography consultant for Oncura Inc cryotherapy systems. Former lead trainer for Urosource mobile medical services , training new surgeons in PVP or photo-selective vaporization of the prostate for BPH, BNCs and urethral stricture vaporization.

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