BPH > Treatment
BPH is most commonly treated with drugs or surgery. Some men with very mild symptoms opt for active surveillance (or watchful waiting), which involves monitoring their condition so that any worsening can be quickly spotted and treated. There are also several ‘minimally invasive’ alternatives, though many of these are relatively new and long-term experience with them is limited.
Drug treatment
Drug treatment may be recommended if your symptoms are moderate, though it may also be beneficial for patients with severe symptoms. Certain complications of BPH, such as kidney problems, urinary retention or bladder stones, make surgery a more appropriate option.
There are two main classes of drug that are prescribed for BPH:
- alpha-blockers
- 5-alpha-reductase inhibitors
These may be administered alone or in combination and there are also some other drugs which are sometimes used.
Alpha-blockers work by helping to relax the muscles at the neck of the bladder and in the prostate. By reducing the pressure on the urethra, they help to overcome the obstruction and so increase the flow of urine. Results available from studies to date indicate that up to 60% of men find that their symptoms improve significantly within the first 2–3 weeks of treatment with an alpha-blocker.
| Alpha-blockers relax the muscles of the neck of the bladder and in the prostate, so reducing the pressure on the urethra. |
This type of drug does not cure BPH, but simply helps to alleviate some of the symptoms. You may still develop complications at a later date and you may still need surgery eventually.
The most commonly occurring side effects are tiredness, dizziness and headache, which affect around one in ten men. The dosage of earlier alpha-blockers had to be increased gradually to reduce the likelihood of side effects, but this is not necessary with more recently developed drugs, such as Flomaxtra (tamsulosin) or Xatral (alfuzosin), which seem to have fewer side effects.
5-alpha-reductase inhibitors work by blocking the conversion of testosterone to another substance, DHT (dihydrotestosterone), that is known to have a key role in prostate growth. To date, most information is available on the 5-alpha-reductase inhibitor Proscar (finasteride); a newer agent, Avodart (dutasteride) is also now available. Unlike alpha-blockers, Proscar and Avodart do appear to be able to reverse the condition to some extent, particularly if the prostate is significantly enlarged, so its use may reduce the likelihood that you will develop acute urinary retention and eventually require surgery. These drugs also seem to work better in patients with larger glands, but it can take 6 months or so for them to be effective. Importantly, they do reduce the PSA value by around 50% so this should be taken into account when monitoring for prostate cancer; one way to do this is to double the PSA value obtained when a patient is taking either Avodart or Proscar.
The main side effects of these agents are a reduced sex drive and difficulty in maintaining/achieving an erection; these appear to affect around 3-5 men in every 100. There is also about a small chance of about 1% or less that you might experience tenderness and swelling around the nipples. These symptoms usually disappear if treatment is stopped. Be aware that crushed or broken Proscar or Avodart tablets should not be handled by a woman who is pregnant or who is planning a pregnancy, as there is a risk that they could cause problems to a developing baby.
Combination therapy with an alpha-blocker or a 5-alpha-reductase inhibitor has been shown (in the Medical Treatment of Prostate Symptoms study) to be more effective than either agent used alone in preventing the worsening of the symptoms of BPH or the development of complications, such as acute retention or the need for surgery. However, the increased cost and additional side effects have to be weighed against these benefits. Patients most likely to respond to combination therapy are those with both a large prostate and severe symptoms.
Other medical strategies for symptom relief in BPH include anticholinergic agents like Detrusitol XL (tolterodine) and Vesicare (solifenacin) to control urinary urgency and frequency. However, these agents carry a small risk of precipitating acute retention of urine in men with severe obstruction and may also result in a dry mouth. Very recently, Botox (Botulinum toxin) has been used in a small number of men with BPH in the form of an injection into the prostate under ultrasound control. Preliminary results look encouraging, but the results of larger, longer studies are needed before it can be regarded as standard therapy.
In patients who are particularly troubled by the need to pass urine during the night (nocturia), vasopressin analogues such as Desmospray or Desmotabs (desmopressin) last thing at night, used in addition to fluid restriction in the evenings, can be quite effective. These drugs work by reducing the amount of urine produced by the kidneys for 6-8 hours.