How Is BPH Treated?

(This information is from Dr. Patrick Walsh's Guide to Surviving Prostate Cancer)

The first option is called watchful waiting, but it doesn't mean "do nothing." It means "wait and see." This is best chosen by men with mild symptoms—those who say they can live with it for the time being. The course of BPH is often hard to predict. Your symptoms could stay the same, improve, or get worse. Men who choose watchful waiting must make an extra effort to avoid any condition (such as constipation) or medication (including over-the-counter cold remedies) that could aggravate the problem. Beyond watchful waiting, there are two basic approaches—medical and surgical.

For men with moderate symptoms, the initial treatment should be medical. Here, again, there are several approaches: one class of drugs is called alpha-blockers. Remember the two kinds of tissue involved in BPH? One is glandular, made up of epithelial cells that secrete the prostate's fluids. The other is smooth muscle tissue— stromal cells that contract and squeeze this fluid into the urethra. As the glandular tissue enlarges and begins to narrow the urethra, the smooth muscle tissue tightens around it like a fist. In the normal prostate, there are two stromal cells for every epithelial cell. But in BPH, this ratio shifts. It's five to one, leading some scientists to describe BPH as a "stromal process." In other words, it's a smooth muscle problem. Alpha-blockers (the same drugs often used to treat high blood pressure) counteract this by causing this muscle tissue to relax. These drugs are helpful in men with small prostates and moderate symptoms.

For men who have a significantly enlarged prostate, it is reasonable to try another class of drugs called 5-alpha reductase inhibitors. These drugs block 5-alpha reductase, the chemical that changes testosterone into dihydrotestosterone (DHT), the active form of male hormone within the prostate. This is important because, scientists have learned, the trouble in BPH starts after testosterone is converted by 5-alpha reductase into DHT. There are two drugs—Avodart (dutasteride) and Proscar (finasteride)—that block the activity of this enzyme. Both appear to work equally well in shrinking the prostate and in decreasing obstructive symptoms. They may also halt the progression of BPH. These drugs neatly manage to block a hormonal process without affecting a man’s levels of testosterone (the hormone responsible for libido and sexual function). However, the problem with these drugs is that the effect is gradual and very slow. To some men, the pace of change is agonizingly slow, with significant improvement coming only after several months to a year of taking these medications. Also, these 5-alpha reductase inhibitors work well only if the prostate is enlarged (men with smaller-sized prostates can have BPH symptoms, too). If the prostate is small, a prostate-shrinking drug isn’t going to solve the problem. And the relief of symptoms lasts only as long as a man takes these drugs.

Testing a Combined Approach

Could 5-alpha reductase inhibitors and alpha-blockers work better together? Is it possible that, for some men, two drugs are better than one? This idea was tested recently in a large, double-blind, placebo-controlled trial. Indeed, long-term use of both an alphablocker and a 5-alpha reductase inhibitor proved safe and reduced the risk of clinical progression—of symptoms getting worse—more than either treatment alone. Men taking both drugs had a lower risk of developing acute urinary retention (the inability to urinate) and were less likely to need invasive therapy. However, the combined therapy is not the miracle answer for every man with BPH. It's expensive, results are not immediate, and although the outcomes of this study were statistically significant, they amounted to only a few percentage points. Further, there is some concern that long-term use of 5-alpha reductase inhibitors may, by artificially lowering a man's PSA level, delay the diagnosis of prostate cancer until it has progressed into high-grade disease (this is discussed in chapter 4).

Surgical Options

For men with severe symptoms or men who do not respond to medical therapy, there are many effective surgical options. The gold standard of these is a procedure called transurethral resection of the prostate (TUR or TURP), also described by patients (although it makes urologists cringe) as the "Roto-Rooter" procedure. It is a proven, effective way to improve BPH symptoms quickly and keep them at bay for years. The TUR is performed under anesthesia (usually spinal anesthesia). Although it is a surgical procedure, the abdomen is not opened up. (Only in rare cases—usually in men with very large prostates—is it necessary to perform an open surgical procedure to remove the prostate tissue surrounding the urethra.) In a TUR, surgeons reach the prostate via the urethra by placing an instrument similar to a cystoscope through the penis. This instrument, called a resectoscope, shines a powerful light that allows surgeons to view the prostate as they chip away at excess tissue. The prostate's core is removed in fragments by means of electrosurgical cautery or laser. These tissue chips collect in the bladder, and at the end of the procedure, they're flushed out, collected, and sent to a pathologist, who examines them and checks for prostate cancer. Because the resectoscope is threaded through the urethra, no skin incision is needed. In recent years, several promising new techniques have been developed. They all channel a form of energy—heat, radio waves, ultrasound, microwaves, and laser—to kill cells. Energy waves are generated, focused, aimed, and fired at the overgrowth of BPH tissue. Some waves work like a shotgun, blasting holes in the prostate. Others are as sensitive as a scalpel, delicately nibbling away at BPH tissue until the urethra is free of obstruction.