Benign Prostatic Hypertrophy (BPH):
Drug and Surgical Treatment Options
What is BPH or an Enlarged Prostate?
Benign prostatic hypertrophy (BPH) is a male condition where the prostate gland grows larger than normal. It is not cancer. The prostate gland is a small gland that is part of the male reproductive tract. It is located below the bladder and in front of the rectum, and wraps around the urethra. The urethra is the tube that carries urine through the penis and out of the body. The prostate gland produces a fluid that mixes with sperm to make semen.
What Causes BPH and What Are the Symptoms?
What exactly causes BPH is not known. As men age past 45 years of age, the prostate gland typical grows larger and may squeeze the urethra, blocking the flow of urine and making urination difficult. Symptoms may become bothersome enough to require treatment by the age of 60 on average. If serious BPH is not addressed, urine may back up into the bladder and lead to urinary infections or kidney damage.
Men may experience these symptoms:
- Feeling that the bladder is not fully emptied
- Difficulty in starting a urine stream
- Frequent nighttime urination
- Pink or red urine due to small amounts of blood
- Little or no urination
How is BPH Diagnosed?
- Blood tests - A blood test that measures the prostate specific antigen (PSA) may be done; if it is elevated, you may have BPH.
- Digital rectal exam - allows a physician to feel the size of the prostate to determine if it is enlarged.
- Cytoscopy - a cytoscope is a long tube, with a camera and a light, that allows a physician to see inside your bladder. The cytoscope is inserted through the urethra. A picture of the prostate or a tissue sample can be collected, if needed.
- Transrectal ultrasound (TRUS) - a probe is inserted in the rectum to look at the prostate, and a video image will appear on a monitor. A TRUS is painless but may be uncomfortable.
- Biopsy - a piece of prostate tissue may be collected for lab testing. This may be done with the guidance of a TRUS.
What Medication Treatments Are Available for BPH?
There are several options for patients who are diagnosed with an enlarged prostate and BPH. Patients with enlarged prostates but no or minimal symptoms typically do not require any treatment at all, and their symptoms can be monitored. However, if symptoms become bothersome and affect quality of lifestyle, several medical and surgical treatments are available.
Medications for BPH - Medications are frequently used for the treatment of symptoms of BPH. Drug treatment with any class of medication used for BPH is typically long-term and continued until symptoms are no longer controlled with drug treatment; at that time surgical procedures may be needed. Drug treatment combinations may also be more effective for some patients than use of a single drug. Common medications used for treatment of an enlarged prostate include:
Alpha-blockers: Alpha-blockers are a class of drugs considered to be first-line treatment for BPH. Alpha-blockers work by blocking the alpha-1a receptor in the prostate and the bladder. Alpha-blockers relax the muscles of the bladder neck and prostate and allow an easier urine flow. Alpha-blockers are very effective in the treatment of BPH; roughly 50 percent of men see an improvement in symptoms within the first 48 hours to one week after therapy initiation. However, patients may only retain symptom relief for up to 4 years, and alpha-blockers do not shrink the prostate or slow down BPH progression. Alpha-blockers are also used to treat high blood pressure. Examples of alpha-blockers used in the treatment of BPH include:
- Terazosin (Hytrin)
- Doxazosin (Cardura, Cardura XL)
- Alfuzosin (Uroxatral)
- Tamsulosin (Flomax)
- Silodosin (Rapaflo)
Side effects that may occur with alpha-blockers include:
- hypotension (low blood pressure), dizziness and possible fainting (terazosin and doxazosin, first dose effect)
- heart fibrillation (fast heartbeats or fluttering in your chest) or chest pain
- floppy iris syndrome (eye complication during cataract surgery)
- abnormal ejaculation
- penis erection that is painful or lasts 4 hours or longer (priapism)
- fatigue or weakness
- swelling in hands, ankles or feet
- nausea, upset stomach
- allergic reactions
Alpha-blockers are usually well-tolerated by most patients. If you should experience a serious side effect, contact your doctor immediately. Also, if you are scheduled to have eye surgery while using an alpha-blocker, be sure to tell all of your doctors.
5-alpha-reductase inhibitors: 5-alpha-reductase inhibitors are another class of drugs that are used to treat an enlarged prostate and BPH. 5-alpha-reductase inhibitors work by blocking dihydrotestosterone to shrink the prostate and increase urine flow. 5-alpha-reductase inhibitors can take three to six months to begin working, and this may be a drawback for many patients. In a small percentage (4%) of patients, 5-alpha-reductase inhibitors can also lead to impotence. Common examples of 5-alpha-reductase inhibitors used in the treatment of BPH include:
Side effects that may occur with 5-alpha-reductase inhibitors include:
- allergic reactions
- breast or high-grade prostate cancer
- decreased sexual drive
- abnormal ejaculation
- gynecomastia (male breast enlargement)
- dizziness or lightheadedness
These side effects do not occur frequently. You should discuss the risk of these side effects with your doctor. If you have questions or think you have experienced a serious side effect, contact your doctor immediately.
Alpha-blockers and 5-alpha-reductase inhibitors can be combined for patients who have more severe urinary symptoms combined with a large prostate. A combination medication, Jalyn, is available commercially, or alpha-blockers and 5-alpha-reductase inhibitors can be taken individually, which may be more cost effective. Your healthcare provider will determine which treatment is best for your condition.
- Dutasteride/Tamsulosin (Jalyn)
What Are the Other Options for Treatment for BPH?
Several types of surgical procedures are available if medications are no longer effective or drug treatment is not an option. Surgical procedures will usually improve urine flow rates and other symptoms. Examples of surgical options for an enlarged prostate include:
- Transurethral resection of the prostate (TURP): This is the most common procedure for BPH. In TURP, a telescoping instrument is inserted through the urethra to reach the prostate gland. An electrical current burns away prostate tissue and creates a larger urethral passage for urine. This surgery takes roughly one to two hours, and may require an overnight stay. General or spinal anesthesia is typically used.
- Transurethral incision of the prostate (TUIP): This procedure is used in men with smaller prostates. In this procedure, a telescoping instrument is inserted through the urethra to reach the prostate gland, as with TURP. A small cut is made in the bladder opening rather than in the prostate gland to widen the urethra opening. No overnight hospital stay is required.
- Transurethral microwave thermotherapy (TUMT): Microwave heat is used to destroy extra tissue on the prostate. This procedure does not require an overnight stay, and although it is a less-invasive procedure, men may need surgery again after five or ten years.
- Simple prostatectomy: This is a major surgical procedure which may require five or more days in the hospital. The inside of the prostate gland is removed through an incision through the lower abdomen. General or spinal anesthesia is required, and the surgery may take two to four hours.
- Prostatic stents may also be used.