Combination Therapy vs. Monotherapy in Benign Prostatic Hyperplasia (BPH): A Malaysian Clinical Perspective   Introduction   Benign Prostatic Hyperplasia (BPH) is a common urological condition among aging men, significantly impacting quality of life due to lower urinary tract symptoms (LUTS). In Malaysia, its prevalence is estimated at around 35% in men aged 50 and above,[3] underscoring the need for appropriate disease management. This article discusses the comparative roles of monotherapy and combination therapy in BPH management, anchored on findings from pivotal clinical trials and aligned with both global and local clinical practice guidelines.[1],[3]   Pathophysiology & Symptoms   BPH is characterized by non-malignant enlargement of the prostate, leading to compression of the urethra and a range of obstructive and irritative urinary symptoms, including frequency, urgency, nocturia, weak stream, and incomplete bladder emptying. These symptoms are driven by both static obstruction (from glandular overgrowth) and dynamic obstruction (from increased smooth muscle tone).[4]    Figure 1: Normal vs Enlarged Prostate Gland Anatomy [Image source: NCBI NBK65915].   Treatment Approaches    Alpha-Blockers   Alpha-blockers, such as tamsulosin and alfuzosin, are considered first-line agents for men with moderate LUTS due to their fast-acting ability to relax smooth muscle in the bladder neck and prostate, resulting in symptom relief.[2] However, they do not influence prostate size or disease progression.[1] 5-alpha reductase inhibitors (5-ARIs)   5-ARIs, including dutasteride and finasteride, inhibit the conversion of testosterone to dihydrotestosterone (DHT), causing gradual shrinkage of the prostate.[4] They are particularly useful in patients with larger prostates (>40 mL) or PSA >1.4 - 1.6 ng/mL, though clinical improvement may take up to six months. Side effects include decreased libido, erectile dysfunction, and reduced ejaculate volume.[1]   Ro