How Tadalafil Helps With Benign Prostatic Hyperplasia

At one time or another, we've all had a good chuckle about erectile dysfunction medications like sildenafil (Viagra) and tadalafil (Cialis). But chuckle as we may, these medications are remarkably effective at helping men with sexual and erectile dysfunction. New research and clinical guidelines suggest yet another use for these medications: used alone or co-administered with drugs like finasteride (Proscar) or dutasteride (Avodart), which are 5-alpha-reductase inhibitors used to treat benign prostatic hyperplasia (BPH).

More specifically, 5-alpha-reductase inhibitors and alpha blockers (such as tamsulosin), another type of BPH drug, do a number on a man's libido and ability to maintain an erection or have normal ejaculation—an adverse effect counteracted by erectile dysfunction meds like Cialis. Moreover, in 2011, the FDA approved Cialis for daily use in treatment of BPH symptoms, too (difficulty with urination). Thus, Cialis is doubly beneficial in those with BPH.

Doctor discussing prostate ultrasound scan with a patient
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What Is BPH?

If you have BPH, you probably need no introduction to its inconvenient, annoying and sometimes very serious symptoms. However, for all of us who are uninitiated, here's some info on this condition.

Benign prostatic hyperplasia is a noncancerous (nonmalignant) enlargement of the prostate gland. In men, the prostate makes semen. In men with BPH, the prostate can become significantly larger and cause urinary obstruction. Of note, the prostate is a doughnut-shaped gland that surrounds the urethra or "pee" tube; the prostate sits just below the bladder.

Although prostate cancer can include hypertrophy and hyperplasia and many of the same initial symptoms as BPH, BPH isn't cancer. It's a benign condition which most men aged 50 or older experience to some degree. Moreover, BPH likely confers no additional risk of developing prostate cancer.

In most men, BPH is asymptomatic and causes no recognizable symptoms. About one-third of American men, however, can experience the following initial symptoms:

  • An urge to urinate more than two times per night (nocturia)
  • Weak urine stream which starts and stops
  • Feeling that you still have to pee even after you just finished urinating
  • Trouble initiating a urine stream (hesitancy)
  • A touch of blood in the urine (hematuria)

Over time, BPH can lead to more serious problems such as urinary tract infections, kidney, and bladder damage. (The obstruction caused by a hyperplastic prostate can cause urine backup which damages the kidney and bladder.)

Initial treatment for BPH is medical management with surgery (TURP) reserved for people who fail medication therapy. Men with symptomatic BPH typically receive two types of medications: alpha blockers (think tamsulosin, terazosin or doxazosin) and 5-alpha reductase inhibitors like the aforementioned finasteride (Proscar) and dutasteride (Avodart). 

The astute reader may notice that both types of BPH medications contain alpha in their names; however, the mechanisms of these drugs are completely different. Alpha blockers relax smooth muscle in the bladder neck and prostate in order to improve urine flow and relieve urinary obstruction. While alpha blocker medication acts quickly within seven days typically, 5-alpha-reductase inhibitors target the hormonal underpinnings of BPH and not only help with urinary flow, but, if taken long enough, can actually shrink the prostate and postpone the need for surgery. Peak effects with 5-alpha reductase inhibitors take longer to be noticed and are achieved after six months of use. The effects of these two types of medications have a greater effect when used together.

Adding Cialis to the Mix

For reasons we can all probably appreciate, a big complaint among many men receiving treatment with alpha blockers, 5-alpha-reductase inhibitors or both is that in 5% to 15% of gents, such meds mess with erectile function, libido, and ejaculation. To counteract this unwanted adverse effect, urologists and primary care physicians have started adding Cialis to the medication mix. Furthermore, in 2011, the FDA had already approved Cialis for treatment of BPH symptoms, too. Thus, in men with BPH, Cialis demonstrates double efficacy—it helps with urination, and it helps with erectile dysfunction.

Fortunately, the science supports the practice of adding drugs chiefly aimed at erectile dysfunction to BPH medication regimens. In a huge randomized-control trial sponsored by Eli Lilly, makers of Cialis (go figure), 695 men were given either Cialis or placebo in addition to the 5-alpha reductase inhibitor finasteride. 

Results were very encouraging with statistically significant improvements in sexual desire, orgasmic function, erectile function, and overall sexual satisfaction observed in those taking Cialis with finasteride. Moreover, adverse effects were few and tolerable. Results were measured at four, 12, and 26 weeks of therapy using a questionnaire titled the International Index of Erectile Function.

As can be expected from many studies using big Pharma funds, research design for this study was pretty tight. Aside from placebo effects, potential limitations for this study include no proven validity that the International Index of Erectile Function was useful when measuring ejaculatory and orgasmic dysfunction and the relatively brief treatment period. Of note, researchers looked only at Cialis co-administration with a 5-alpha-reductase inhibitor, not an alpha-blocker, too. Typically, alpha-blocker medication and Cialis or other PDE5 inhibitors at elevated doses are contraindicated together.

Closing Thoughts

If you or someone you love is experiencing sexual difficulties secondary to BPH medications like finasteride and aren't already on Cialis, be sure to tell your primary care physician or urologist. The addition of Cialis to your treatment regimen is safe and tolerable and should help with your sex life and symptoms of BPH itself. 

On a related note, because of its hormonal effects, lower-dose finasteride is also marketed as Propecia, a drug given for hair loss. Although people who typically take Propecia are younger men with fewer erectile dysfunction issues, and Propecia is lower dose than Proscar, Propecia may also interfere with sexual functioning and possibly male fertility. If you're taking finasteride to prevent hair loss and are experiencing erectile dysfunction, libidinal problems, or fertility issues, be sure to inform your prescribing physician.

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Additional Reading
  • Fode M, Sønksen J, McPhee SJ, Ohl DA. Disorders of the Male Reproductive Tract. In: Hammer GD, McPhee SJ. eds. Pathophysiology of Disease: An Introduction to Clinical Medicine, Seventh Edition. New York, NY: McGraw-Hill; 2013.