Benign Prostatic Hyperplasia (BPH): Overview of Medication Options
Benign prostatic hyperplasia (BPH) is a condition that refers to the enlargement of the prostate, the walnut-sized gland that is part of the male reproductive system. The prostate contributes part of the fluid that semen consists of. Additionally, the prostate surrounds the male urethra, which is the passageway for urine to flow from the bladder to and then through the penis.
The prostate usually enlarges with age, and symptoms begin to occur most commonly when men are in their fifties and sixties. Up to 50% of men in their sixties and up to 85% of men in their seventies are bothered by the symptoms of BPH.
As the prostate grows, it compresses the urethra, and as a result, symptoms occur. The most common symptoms include urinary frequency, urgency, a decreased urinary stream, which may be interrupted, and waking at night to urinate.
It wasn’t that long ago that a procedure known as a TURP (transurethral resection of the prostate; or commonly referred to by patients as the "roto-rooter") was one of the most commonly performed surgical procedures in the US. Recently, however, due to a large amount of clinical research, medical therapy is most commonly utilized.
The most common means of treatment for BPH today is with the use of various drugs that help to either relax the opening of the bladder or the bladder neck, or shrink the volume of the prostate. Alpha-blockers were the first category of drugs used to treat the prostate. Historically some of these medications have been tried but are not in widespread usage today. The first of these, Minipress (prazosin) was introduced in 1976, however, despite its favorable effect on the bladder, its use was limited by the side effects of low blood pressure and dizziness. In 1987, Hytrin (terazosin) was introduced, another medication that also had some effect on blood pressure; however, by slowly increasing the dose of the medication, the blood pressure lowering effects were diminished. Cardura (doxazosin), another drug similar to terazosin, also became available, and this too had blood pressure effects, although not as great as that seen with terazosin.
Subsequent to these agents, more selective alpha blocking drugs have been developed. These drugs do not exert any anti-hypertensive side effects and are very effective in reducing the symptoms of prostatic enlargement. Drugs such as Flomax (tamsulosin), Uroxatral (alfuzosin) and Rapaflo (silodosin) are all available. Side effects with these drugs can include stuffy or runny nose, low blood pressure, dizziness, diarrhea or orgasm with little or no semen. This category of drugs tends to be tolerated by patients for long-term use.
In addition to drugs that relax the prostate and bladder neck opening, other drugs are available that shrink the size of the prostate. These medications - Proscar (finasteride) and Avodart (dutasteride) - are in the category of 5 alpha-reductase inhibitors (5ARIs) and work by interfering with the metabolism of testosterone to a by-product known as di-hydrotestosterone (DHT).
DHT is a potent byproduct that is responsible for facial and body hair growth, deepening of the voice, and prostatic growth. DHT also plays a role in male pattern balding and acne development. The drug Propecia (a form of finasteride) is utilizedfor male pattern balding. By inhibiting the formation of DHT, a decrease in prostate volume occurs. Long tem studies with these drugs have demonstrated a significantly decreased risk of developing urinary retention or undergoing prostatic surgery. Mild erectile dysfunction has been reported in patients using these drugs. A decrease in sex drive and ejaculatory dysfunction may also be experienced.
Dietary supplements such as saw palmetto also inhibit the formation of DHT, however not as specifically as the pharmaceutical products. Special attention needs to be paid to the patient’s PSA while on these drugs, as these drugs may interfere with the interpretation of the patients PSA.
The newest drug that has been released is Jalyn, which is a combination drug. This agent combines the best of both worlds by joining an alpha-blocker (tamsulosin) with a 5 ARI (dutasteride). Many patients are on combination therapy and theoretically this would help cut cost for patients. However, these medications tend to have higher copays or are not covered by managed care companies. The pharmacologic approach to the treatment of BPH is very attractive to patients, however, not all patients respond to pharmacotherapy and will need to rely on a minimally invasive surgical approach to solve the problems that their prostate is causing.
Jay Motola, MD, is a board-certified urologist and attending physician, Department of Urology, Mount Sinai West, and Assistant Professor of Urology, Icahn School of Medicine at Mount Sinai. Dr. Motola is a summa cum laude, Phi Beta Kappa graduate of Boston University, and earned his medical degree at the State University of New York at Stony Brook.