Treatment Options for an Enlarged Prostate
Men who eventually need treatment for benign prostatic hyperplasia (BPH), also known as benign prostatic enlargement (BPE), typically experience a progressive decrease in the size and force of their urinary stream or a sensation of incomplete emptying of their bladder. Although frequent nighttime urination is one of the most annoying symptoms of BPH, it does not predict the need for future treatment.
If urethral obstruction worsens and is left untreated, complications can occur. Potential complications include a thickened bladder with a reduced ability to store urine, infected residual urine, bladder stones, and a backup of pressure that damages the kidneys.
Treatment decisions for BPH are based on the severity of symptoms as assessed by the International Prostate Symptom Score questionnaire, the extent of urinary tract damage, and the man’s age and overall health.
In general, no treatment is needed for men who have only a few symptoms and are not bothered by them. Treatment—usually surgery—is required when there is kidney damage due to inadequate bladder emptying; a complete inability to urinate after treatment of acute urinary retention; incontinence due to overfilling or increased bladder sensitivity; bladder stones; infected residual urine; recurrent blood in the urine despite treatment with medication; or symptoms that have not responded to medication and are troublesome enough to diminish quality of life.
Treatment decisions are most difficult for men who have moderate symptoms. Each of these men must determine whether the symptoms bother him enough or interfere with his life enough to merit treatment.
The main treatment options for BPH are watchful waiting (close monitoring but no immediate treatment), plant-based remedies (phytotherapy), medication, surgery, and minimally invasive procedures. If medications do not relieve symptoms in a man who is not a candidate for surgery (for example, because he is unable to withstand the rigors of surgery), urethral obstruction and incontinence may be managed with intermittent catheterization or with an indwelling Foley catheter (a catheter with a balloon at its tip that, when inflated, holds the catheter in place in the bladder). The catheter is usually changed monthly.
Because the course of BPH is unpredictable, watchful waiting is the best option for men with minimal symptoms that are not especially bothersome. With this management option, physician visits are needed about once a year to review symptom status, conduct a physical examination, and perform a few simple laboratory tests.
During watchful waiting, men should adopt certain lifestyle measures to help relieve symptoms or prevent them from worsening. For example, they should not take over-the-counter antihistamines or decongestants and should avoid delaying urination. They also need to limit the amount of fluid consumed at any one time and not drink anything after 7 p.m. In addition, they should avoid beverages that contain caffeine, limit alcohol intake, and cut back on spicy or salty foods. Engaging in regular physical activity, doing Kegel exercises, and keeping warm also can be helpful.
The association between lower urinary tract symptoms and cold weather is probably related to increased sympathetic activity (the sympathetic nervous system is more active in cold weather), which causes increased smooth muscle tone within the prostate. Also, preventing weight gain (especially around the middle), eating a diet rich in vegetables, and keeping blood sugar under control may help reduce lower urinary tract symptoms.
Some people elect to use dietary supplements that contain substances derived from plants or minerals to manage their symptoms. Saw palmetto is the most well-known remedy, but African plum, Trinovin, South African star grass, flower pollen extract, soy, stinging nettle, rye pollen, purple coneflower and pumpkin seeds also are used to manage BPH symptoms, as are supplements of the minerals zinc and selenium.
A dietary supplement called beta-sitosterol has shown some benefits in BPH, including improvements in urinary symptoms and urine flow rates. However, well-conducted studies of beta-sitosterol are limited. Much more research has been done on saw palmetto. Although some studies had shown benefit, the most recent findings from well-designed studies found no advantage.
If the supplements relieve your symptoms, you may want to continue taking them, but let your doctor know. The typical dose of saw palmetto is 160 mg taken twice a day. Supplements that contain at least 85 percent free fatty acids and at least 0.2 percent sterols are the most likely to be effective. If you’re still experiencing lower urinary tract symptoms after using saw palmetto for 90 days, talk to your doctor about other options. The adverse effects related to saw palmetto are usually mild and infrequent. They include headache, dizziness, nausea and mild abdominal pain.
The two types of medications most commonly used to treat BPH are alpha-1-adrenergic blockers (alpha-blockers) and 5-alpha-reductase inhibitors (5ARIs). Research suggests that these drugs improve symptoms in approximately 30 to 60 percent of men. However, it is not possible to predict who will respond to medication or which drug will work best for a particular person. However, 5-ARIs should be used only in men with prostate enlargement (prostate volume over 40 mL), since they work by reducing prostate volume.
• Alpha-1-adrenergic blockers. Alpha-blockers relax smooth muscle tissue within the prostate by blocking the effect of nerve impulses that signal the muscles to contract. As a result, daily use of an alpha-blocker may increase urinary flow and relieve urinary frequency, urinary urgency, and frequent nighttime urination. Currently, several alpha-blockers are used to treat BPE.
One advantage of alpha-blockers over 5ARIs is that they work almost immediately. In addition, they can treat high blood pressure (hypertension) in men with that condition.
In men with small prostates, symptoms are more likely to result from smooth muscle constriction rather than from physical obstruction caused by excess glandular tissue. Thus, alpha-blockers that relax smooth muscle are superior to 5-ARIs among men with small prostates (volume below 40 mL). However, the two drugs in combination are more effective than either drug alone for men with large prostates (volume greater than 40 mL).
Men who have both BPH and an overactive bladder may benefit from treatment with an alpha-blocker and a drug used to treat overactive bladder, such as tolterodine (Detrol). In one study, men who took both Flomax and Detrol experienced greater improvements in their lower urinary tract symptoms than did men taking either medication alone.
Alpha-blockers can cause side effects such as orthostatic hypotension (dizziness upon standing due to a drop in blood pressure), fatigue, insomnia, and headache. These side effects are less common with Flomax because it does not lower blood pressure as much as the other alpha-blockers. Taking the drugs in the evening can minimize the risk of orthostatic hypotension.
Men who take alpha-blockers should be aware that these medications may interact with oral phosphodiesterase type 5 (PDE5) inhibitors used to treat erectile dysfunction (ED) as the combination also can lead to hypotension. The current recommendation is that the PDE5 inhibitors sildenafil (Viagra) and vardenafil (Levitra) not be taken within four hours of taking an alpha-blocker.
Among men taking blood pressure medication, alpha-blocker dosages may need to be adjusted to account for the drugs’ blood pressure-lowering effects. Alpha-blockers may induce angina (chest pain resulting from an inadequate supply of oxygen to the heart) in men with coronary heart disease.
Men taking alpha-blockers who plan to undergo cataract surgery should tell their eye surgeon they are using the medication. Use of alpha-blockers has been found to make a man’s iris more “floppy” during cataract surgery (a condition called floppy iris syndrome). However, the surgeon can modify the surgical technique to avoid this problem if he or she is aware of the alpha-blocker use prior to the operation.
• 5-alpha-reductase inhibitors. Two 5-alpha-reductase inhibitors (5-ARIs), are used to treat BPH: finasteride (Proscar) and dutasteride (Avodart). These medications inhibit the enzyme 5-alpha-reductase, which converts testosterone to dihydrotestosterone (DHT), the major male sex hormone within the cells of the prostate. Medications in this class work best in men with larger prostates—40 mL (approximately 1.5 oz.) or more—whose symptoms likely result from physical obstruction of the urethra.
The two 5ARIs are equally effective. Both can reduce the size of the prostate by 20 to 30 percent, relieve BPH symptoms and reduce the risk of acute urinary retention and the need for BPE surgery. However, these drugs must be continued indefinitely to prevent symptom recurrence. Moreover, it may take as long as one year in order to achieve maximal benefits.
Proscar and Avodart cause relatively few side effects. ED (the inability to achieve a full erection) occurs in 5 to 8 percent of men, decreased libido (sex drive) in 3 to 6 percent, reduced ejaculate in 1 percent and breast enlargement or tenderness in 0.5 percent. Typically, sexual side effects tend to decrease with time, and they disappear when the drug is stopped, although this is not always the case. Breast-related side effects do not diminish with time but often improve once the drug is no longer taken.
Another side effect of both Proscar and Avodart is that they lower PSA levels by about 50 percent. If not taken into account, this can interfere with the results of PSA tests to detect prostate cancer. Men should have a PSA test prior to starting treatment with any 5ARI so that subsequent PSA values can be interpreted in light of this baseline value. If a man is taking a 5ARI and no baseline PSA level was obtained, his current PSA test results should be doubled to estimate the “true” PSA level.
A PSA level that falls less than 50 percent after a year of treatment with a 5ARI suggests that the drug is not being taken as directed or that prostate cancer might be present. Similarly, an increase in PSA levels while taking a 5ARI suggests the possibility of prostate cancer. PSA values return to their true level after the 5ARI is stopped.
The medication Propecia, which is a lower dose of finasteride marketed for the treatment of male pattern baldness, also lowers a man’s PSA value to the same extent as Proscar. Men who use Propecia should alert their physician so their PSA results can be adjusted accordingly.
In 2011 the Food and Drug Administration (FDA) required a new warning on labels for all three drugs stating that they are associated with a small but increased risk of aggressive (high-grade) prostate cancer. The warning also applies to the combination drug Jalyn, which contains the 5-ARI dutasteride and tamsulosin. The FDA believes that 5-ARIs are safe and effective for BPH. But, if you are taking one, talk to your doctor about how often you should be screened for prostate cancer.
• Combination therapy. The AUA endorses the use of combination therapy for men with moderate to severe symptoms and clinical evidence of significant prostate enlargement. The AUA bases its recommendation on the results of several studies. The first was the MTOPS trial. The 4.5-year investigation involved more than three thousand men who had BPH symptoms, making it the largest trial ever to compare various types of medication for the treatment of BPE. The participants were randomly assigned to one of four treatment groups: Proscar; Cardura; a combination of the two; or a placebo (inactive substance).
The researchers found that combination therapy was safe and appeared to be more effective than either medication alone (Proscar or Cardura). Men on combination therapy were 66 percent less likely to experience worsening of their BPE during the study than were men who took the placebo. Men who took Cardura alone were 39 percent less likely to experience worsening symptoms; those who took Proscar alone were 34 percent less likely. Combination therapy also reduced the risk of acute urinary retention by 79 percent compared with placebo. The risk reduction was 67 percent with Proscar, but Cardura did not significantly affect urinary retention rates.
Other research that has shown good results from combination therapy is the Combination of Avodart and Tamsulosin (CombAT) study. In this trial, published in BJU International, men with BPE who were given combination therapy with the 5-alpha-reductase inhibitor Avodart and the alpha-blocker Flomax were less likely than other men who received only Flomax to experience worsening symptoms, develop acute urinary retention, or need surgery. The men in this study had prostate enlargement with moderate to severe BPE symptoms. As mentioned previously, a combination drug containing Avodart and Flomax (Jalyn) is available.
Combination therapy has been shown to be most effective in men with larger prostates because Proscar and Avodart work by reducing prostate size. Older men, those with higher PSA levels, and men with low urinary flow rates are more likely than other men to have an enlarged prostate.
The ED drug Cialis is approved to treat lower urinary tract symptoms. Studies have shown that this ED drug significantly improves urinary symptoms compared with placebo. Many men with lower urinary tract symptoms have coexistent ED. Urologists will often prescribe Cialis as a first-line treatment for men who have both ED and urinary symptoms rather than starting with an alpha-blocker. A 5-ARI plus Cialis may be prescribed rather than an alpha blocker for men with prostate enlargement who have both ED and urinary symptoms.