Identifying and Treating BPH (Enlarged Prostate)
We have heard so much lately about prostate cancer that perhaps it is time to turn back to the basics, and look at BPH (benign prostatic hyperplasia), a condition that affects far more men than prostate cancer. Recently, the prostate is a source of much controversy including the significance of PSA testing, the possible development of high grade prostate cancer with the use of medications that are commonly used to shrink prostate cancer and the need to treat prostate cancer. However despite all the controversies surrounding prostate malignancy, the symptoms that occur as a result of BPH are undeniably a continuing source of ongoing concern amongst most middle aged men.
As the prostate grows, the nodules that arise and progress in size, eventually compressing the urethra. The result is symptoms of either obstruction or irritability of the lower urinary tract. Patients may experience a decrease in their force of stream, waking up at night to urinate, frequency of urination, urinary dribbling, and a sense of incomplete emptying and intermittency of their urine flow. Some patients may develop urinary tract infections or even bladder stones that need to be treated surgically.
The treatment of prostate enlargement can be undertaken in a medical manner with the use of various medications or with an assortment of surgical techniques, some being minimally invasive. The medications work in two different manners. Drugs in the category of alpha-blockers include the more commonly used medications such as tamsulosin (Flomax), alfusozin (Uroxatrol) and silodosin (Rapaflo). Earlier medications such as terazosin (Hytrin) are also used by some but not as commonly. These drugs work by relaxing muscular fibers that surround the opening of the bladder and the prostate. When taking these medications, the muscle relaxes and the urine is able to more freely flow through the prostate. Patients may experience side effects with these medications that include light-headedness, feeling tired towards the end of the day, nasal stuffiness and loss of ejaculation, (but not interfering with the ability to have an erection).
Another category of medications are the drugs that are 5 alpha-reductase inhibiting agents and include the medications finasteride (Proscar) and dutasteride (Avodart). These drugs block the conversion of testosterone to dihydrotestosterone and as a result, the prostate usually will shrink in size. Most patients experience a decrease in their semen production when using these medications and some may experience erectile difficulties.
The newest drug on the market, Jalyn, is a drug that combines a 5 alpha-reductase inhibitor (dutasteride) with tamsulosin (an alpha-blocker). Drugs in this category were held in very high regard; however, a recent FDA warning cited a very slight increased incidence of developing high-grade prostate cancer when using these agents long-term causing some to question their widespread use. The increased incidence is cited as .5 percent increase for dutasteride and 1.3 percent increase for finasteride. Contrarily however, these drugs are also associated with a 24% reduction in the more common forms of prostate cancer. This warning has posed a dilemma with regards to prescribing drugs in this category of medication, however most patients after being counseled about the risks and benefits of these medications, decide to be maintained on these drugs provided that their PSA readings are normalized, and their digital examinations are normal.
Even when using medications to control their symptoms, patients may still have persistent symptoms that they find bothersome. The most bothersome persistent symptom, urinary frequency, can often be controlled with the use of anti-cholinergics, such as ditropan, Toviaz, Sanctura or Enablex.
Despite all the medications that are available, not all patients respond to these agents, and some will require surgical intervention to treat the underlying obstruction. The goal of these procedures is to reduce the volume of the prostate, essentially creating a channel through the central portion of the prostate. The TURP (transurethral resection of the prostate) is still the gold standard, however other less invasive procedures are now more popular. Lasers and microwave therapy both are minimally invasive alternative means of relieving prostatic obstruction. There are advantages and disadvantages to all of these procedures, and a discussion with your Urologist will help you to determine which is the correct alternative for you.
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.