Comparative efficacy and safety of alpha-adrenoblockers in the treatment of LUTS due to BPH: a systematic review and meta-analysis

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Abstract

Introduction. Lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) are common and significantly impair quality of life. Alpha-1 adrenergic blockers (ABs) are the first-line pharmacotherapy; however, direct comparative data between individual agents remain limited.

Objective. To systematically compare the efficacy and safety of silodosin, tamsulosin, alfuzosin, terazosin, and doxazosin in men with LUTS/BPH.

Materials and Methods. A comprehensive search was performed in eLibrary, PubMed, Embase, and the Cochrane Library from July to September 2025. Randomized controlled trials (RCTs) evaluating AB monotherapy in men with LUTS/BPH were included. Primary outcomes were the International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), post-void residual urine volume (PVR), quality of life (QoL), and incidence of adverse events (AEs). Study selection and data extraction were conducted in duplicate. Risk of bias was assessed using Cochrane RoB 2. Pairwise meta-analyses (random-effects model, RevMan) and a network meta-analysis with placebo as a common comparator were performed. Certainty of evidence was evaluated using the GRADE approach.

Results. Twenty-two RCTs (n=3,371; median follow-up = 12 weeks) were included; 20 were eligible for quantitative synthesis. Compared with placebo, all ABs significantly improved symptom and uroflow parameters: pooled mean difference for IPSS = –2.3 to –2.5 points; increase in Qmax = +2 mL/s; reduction in PVR = –10 to –20 mL; improvement in QoL = –0.4 points. Network analysis revealed no statistically significant efficacy differences among agents. Rank probability suggested slightly greater improvements in IPSS/Qmax/PVR with tamsulosin, and in QoL with doxazosin, though differences were clinically marginal. Safety profiles varied: dizziness and orthostatic hypotension were more frequent with doxazosin/terazosin, while ejaculatory dysfunction occurred more often with silodosin (≈ 20–25%) and, to a lesser extent, tamsulosin (8–10%). The rate of discontinuation due to AEs was comparable to placebo; serious AEs were rare.

Conclusion. Alpha-1 adrenergic blockers as a class effectively reduce LUTS and improve urinary flow parameters in men with BPH. No clinically meaningful superiority of any single agent has been demonstrated. Treatment choice should be individualized according to comorbidities and tolerability profile. Large-scale head-to-head trials are warranted to confirm potential subtle differences.

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About the authors

Oleg B. Loran

State Budgetary Healthcare Institution of the city of Moscow «Moscow Multidisciplinary Scientific and Clinical Center named after S.P. Botkin» of the Department of Health of the City of Moscow; Federal State Budgetary Educational Institution of Additional Professional Education «Russian Medical Academy of Сontinuing Professional Education» of the Ministry of Health of the Russian Federation

Email: oleg_loran@gmail.com
ORCID iD: 0000-0002-7531-1511
SPIN-code: 7604-8138

Honored Scientist of Russian Federation, M.D., Dr.Sc.(M), Full prof., Head, Dept. of Urology and Surgical Andrology, Full member of the European and International Associations of Urologists

Russian Federation, Moscow; Moscow

Vladimir A. Vorobev

Bashkir State Medical University; Irkutsk State Medical University

Author for correspondence.
Email: denecer@yandex.ru
ORCID iD: 0000-0003-3285-5559
SPIN-code: 9896-6243

Doctor of Medical Sciences, M.D., Professor of the Department of Faculty Surgery and Urology, Associate Professor of the Department of Urology and Oncology

Russian Federation, Ufa; Irkutsk

Inga V. Kosova

Federal State Budgetary Educational Institution of Additional Professional Education «Russian Medical Academy of Сontinuing Professional Education» of the Ministry of Health of the Russian Federation

Email: Kosovainga@mail.ru
ORCID iD: 0000-0002-0051-0583

Urologist at the Department of Urology at the State Budgetary Healthcare Institution of the city of Moscow City «Clinical Hospital named after V. P. Demikhov» of the Department of Health of the City of Moscow, Professor of the Department of Urology and Surgical Andrology

Russian Federation, Moscow

Zaida K. Gadzhieva

FGAOU VO I.M. Sechenov First Moscow State Medical University

Email: zgadzhieva@ooorou.ru
ORCID iD: 0009-0004-5442-1334
SPIN-code: 8695-3024

Doctor of Medical Sciences, M.D., Head of the Department for Human Resources Policy Analysis, Educational Programs and Research at the National Medical Research Center for Urology, Scientific Editor of the journal «Urology», Deputy Executive Director of the Russian Society of Urology (RSU)

Russian Federation, Moscow

Mikhail I. Kogan

Rostov State Medical University

Email: dept_kogan@mail.ru
ORCID iD: 0000-0002-1710-0169
SPIN-code: 6300-3241

Honored Scientist of Russian Federation, Doctor of Medical Sciences, M.D., Professor, Head of the Department of Urology and Human Reproductive Health (with the pediatric Urology and andrology сourse)

Russian Federation, Rostov-on-Don

Kirill M. Su-Yanz

Irkutsk State Medical University

Email: KirillSu15@yandex.ru
ORCID iD: 0009-0005-9143-916X
SPIN-code: 3561-4106

5th-year student of the Faculty of General Medicine

Russian Federation, Irkutsk

Amina I. Syrova

Irkutsk State Medical University

Email: syrovamina2003@gmail.com
ORCID iD: 0009-0001-9400-1738
SPIN-code: 6174-0970

5th-year student of the Faculty of General Medicine

Russian Federation, Irkutsk

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2. Fig. 1. The flow of the PRISMA diagram, showing the results of the search and selection of studies

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3. Fig. 2. Synthesis of evidence and GRADE

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4. Fig. 3 A-D. Generalized results of the meta-analysis of efficacy: forest diagrams of comparisons of drugs with placebo by outcome: Figure A — IPSS, Figure B — Qmax, Figure C — PVR, Figure D — QoL.

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