Following on from a diagnosis of BPH or benign prostatic enlargement, it’s important to be aware that there are several treatment options available to you. These include a range of options from observation, medication, minimally invasive treatment choices or definitive therapy with cavitating procedures.
This blog post aims provides you with some information about your treatment choices with the medical management of BPH. The first thing to be aware of is that following a diagnosis of BPH there are several treatment options that are available for a man to try and improve the situation. The simplest thing is an expectant pathway, which means that we accept that there are some urinary symptoms related to the benign enlargement of the prostate but from a quality of life point of view these symptoms may not adversely affect someone’s quality of life. Therefore, we observe and just monitor their progress.
We’re going to concentrate on the medical management of BPH which will hopefully answer some of your questions that you may have. There are three main classes of medicines that can be used to treat a BPH. They include alpha blockers, five alpha reductase inhibitors, and phosphodiesterase type 5 inhibitors.
The alpha blockers are the most common type of medication that we use to treat BPH and really they represent our entry-level management. Alpha blockers work at the level of the bladder neck. The bladder neck is the junction between the bladder and the prostate. They also result in relaxation of the smooth muscle through the prostatic urethra which is in the centre part of the prostate. Examples in Australia include drugs like prazosin and also tamsulosin. They result in relaxation of smooth muscle inside the prostate and the bladder neck.
There are different types of alpha blocker: there are titratable and there are non-titratable. The titratable ones in essence mean that we start off at a low dose and we gradually increase the dose that someone takes until we get the therapeutic benefit in their urinary symptoms. We balance this against any potential side effects.
There are non-titratable alpha blockers whereby someone takes one pill per day. The most common side effects that we see include something called postural hypotension which, in essence, means that someone’s blood pressure can lower when they stand from either sitting or lying down. It can result in someone feeling a bit dizzy or a little bit lightheaded at that time. The other common side effect is something called rhinitis, which manifests like a bit of a head cold. People feel like they have pressure in their front sinuses or they can have a slight runny nose. In younger men they can experience something called retrograde ejaculation which is where they have an orgasm but there is no fluid that is emitted.
Five alpha reductase inhibitors, examples of which include, finasteride or dutasteride. These medications can be used alone or they can be used in combination with an alpha blocker. In essence what a5 ARI does is prevent testosterone being converted into its active form inside the prostate. The net result of this is that if taken for a long enough period of time i.e six months or more, there can be a gradual shrinkage in the prostate of about 20-30%.Five alpha reductase inhibitors are ideally suited for those people that have a slightly bigger prostate, they empty their bladder incompletely, are older men over the age of 65 and have a psa above 1.4. There is good data from previous publications that looks at the combination of 5 ARIs together with alpha blockers. In Australia there is a product called Duodart which contains tamsulosin, an alpha blocker, together with dutasteride a 5ari in a single tablet. This tablet can be used for people if they fulfil certain criteria from a prostate perspective and these men can get a bigger more durable improvement.
The final alternative are phosphodiesterase type 5 inhibitors. These medications are used for individuals who have erectile dysfunction but these drugs can also be used in a low dose to try to improve not only urinary function but sexual function as well. A commonly used drug for this scenario is something called tadalafil.
Tadalafil can be used in a low dose on a daily schedule to effect improvements in urinary symptoms and also erectile function. Again the trade-off is that it’s a tablet that needs to be taken every day and the most common side effects that happen in about 10-20 % of people include flushing, a headache, sometimes indigestion or rarely muscular pains.
Ultimately which medication or combinations of medications an individual chooses is very much a personal one and will depend on the degree of bother that a man experiences from his urinary function.