When is BPH treatment necessary?
The course of BPH in any individual is not predictable. Symptoms, as well as objective measurements of urethral obstruction,
can remain stable for many years and may even improve over time as many as one-third of men, according to some studies.
In a recent study from the Mayo Clinic, urinary symptoms did not worsen over a three-and-a-half-year period in 73% of men with mild BPH.
A progressive decrease in the size and force of the urinary stream and the feeling of incomplete emptying of the bladder are the symptoms
most correlated with the eventual need for treatment. Although nocturia (frequent nighttime urination) is one of the most annoying symptoms
of BPH, it does not predict the need for future intervention.
Decisions regarding treatment are based on
the severity of symptoms (as assessed by the AUA Symptom Index), the extent
of urinary tract damage, and the man's and overall health. In general no treatment
is indicated in those who have only a few symptoms and are not bothered by them.
Intervention -usually surgical- is required in the following situations:
Treatment options for BPH
Currently, the main treatment options for BPH are:
One study published last year suggests that finasteride may be best suited for men with relatively large prostate glands. An analysis of six studies found that finasteride only improved BPH symptoms in men with an initial prostate volume of over 40 cc (cubic centimeters); finasteride did not reduce symptoms in men with smaller glands. Since finasteride shrinks the prostate, men with smaller glands are probably less likely to respond to the drug because the urinary symptoms result from causes other than physical obstruction (for example, smooth muscle constriction). A recent study showed that over a 4-year period of observation, treatment with finasteride reduced the risk of developing urinary retention or requiring surgical treatment by 50%
Finasteride causes relatively few side effects. Impotence occurs in 3 to 4% of men taking the drug. Finasteride may also decrease the size of the ejaculate. Another adverse effect is gynecomastia (breast enlargement). About 80% of those who stopped taking the drug had a partial or full remission of their breast enlargement. A study from England found gynecomastia in 0.4% of patients taking the drug. Because it is not clear that the gynecomastia is caused by the drug or increases the risk of breast cancer, men taking the drug are being carefully monitored until these issues are resolved.
Finasteride can lower PSA levels by about 50%, but is not thought to limit the utility of PSA as a screening test for prostate cancer. The fall in PSA levels, and any adverse effects on sexual function, disappear when finasteride is stopped.
To get the benefits of finasteride for BPH without compromising the detection of early prostate cancer, men should have a PSA test before starting treatment with finasteride; subsequent PSA values can then be compared to this baseline value. If a man is already on finasteride and no baseline PSA level was obtained, the results of a current PSA test should be multiplied by two to estimate the true PSA level. A fall in PSA of less than 50% after a year of finasteride treatment suggests either that the drug is not being taken or that prostate cancer might be present. Any increase in PSA levels while taking finasteride also raises the possibility of prostate cancer.
An advantage of alpha blockers, compared to finasteride, is that they work almost immediately; they have the additional benefit of treating hypertension when it is present in BPH patients. However, whether terazosin is superior to finasteride may depend more on the size of the prostate. When the two drugs were compared in a study published in The New England journal of Medicine, terazosin appeared to produce greater improvement of BPH symptoms and urinary flow rate than finasteride. But this difference may have been due to the larger number of men in the study with small prostates, who would be more likely to have BPH symptoms from smooth muscle constriction, rather than from physical obstruction by excess glandular tissue. Doxazosin was evaluated in three different clinical studies involving 337 men with BPH. Patients took either a placebo or 4 to 12 mg of doxazosin a day. The active drug- reduced urinary symptoms by 40% more than the placebo, and increased the urinary peak flow by an average of 2.2 ml/s (compared to 0.9 ml/s in the placebo patients).
Despite the previously held belief that doxazosin was only effective for mild or moderate BPH, patients with severe symptoms experienced the greatest improvement. Side effects-including dizziness, fatigue, hypotension (low blood pressure), headache, and insomnia-led to withdrawal from the study by 10% of those on the active drug, and 4% of those taking the placebo. In men treated for hypertension, the doses of other antihypertensive drugs may need to be adjusted to account for the blood-pressure-lowering effects of an alpha-adrenergic blocker. These drugs may also induce angina in men with coronary heart disease. A doctor will be able to determine which individuals are good candidates for their use.
Surgery ( Prostatectomy)
Surgery is also associated with the greatest number of long-term complications, including:
Surgery is delayed until any urinary tract infection is successfully treated and kidney function is stabilized (if urinary retention has resulted in kidney damage). Men taking aspirin should stop taking the drug 7 to 10 days prior to surgery, since aspirin interferes with blood's ability to clot. Transfusions are required in about 6% of patients after TURP and 15% of patients after open prostatectomy.
Since the timing of prostate surgery is elective, men who may need a transfusion-primarily those with a very large prostate, who are more likely to experience significant blood loss-have the option of donating their own blood in advance, in case they need it during or after surgery. This option is referred to as an autologous blood transfusion.
Transurethral prostatectomy (TURP)
Improvement after surgery is greatest in those with the worst symptoms. Marked improvement occurs in about 93% of men with severe symptoms and in about 80% of those with moderate symptoms. The mortality from TURP is very low (0.1%); however, impotence follows TURP in about 5 to 10% of men and incontinence occurs in 2 to 4%.
Transurethral incision of the prostate (TUIP)
In the past, open prostatectomies for BPH were carried out either through the perineum (the area between the scrotum and the rectum)-called perineal prostatectomy--or through a lower abdominal incision. Perineal prostatectomy has largely been abandoned for the treatment of BPH due to the higher risk of injury to surrounding organs, though it is still used for prostate cancer. Two types of open prostatectomy for BPH-suprapubic and retropubic-employ an incision extending from below the umbilicus (navel) to the pubis. A suprapubic prostatectomy involves opening the bladder and removing the enlarged prostatic nodules through the bladder. In a retropubic prostatectomy, the bladder is pushed upward and the prostate tissue is removed without entering the bladder. In both types of operation, one catheter is placed in the bladder through the urethra, and another through an opening made in the lower abdominal wall. The catheters remain in place for three to seven days after surgery. The most common immediate postoperative complications are excessive bleeding and wound infection (usually superficial). More serious potential complications include heart attack, pneumonia, and pulmonary embolus (blood clot to the lungs). Breathing exercises, leg movements in bed, and early ambulation are aimed at preventing these complications. The recovery period and hospital stay are longer than for transurethral prostate surgery.Treatments under investigation
A number of other treatment options have been -or are currently being - evaluated for BPH.
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