Harvard Men's Health Watch

Try medication first for urinary woes

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Either medication or surgery can help with symptoms like an uncontrollable urge to urinate.

Give it ample time to work before considering surgery.

As men get older, they may begin to experience bothersome urinary symptoms like frequent urination at night, difficulty completely emptying the bladder, and the urgent need to urinate at inconvenient times. The cause is often a noncancerous overgrown prostate gland, which many men know as benign prostatic hyperplasia (BPH).

The first choice for treating BPH is medication, but sometimes it just doesn't provide a long-term solution. The drugs may trigger unacceptable side effects or may not work as well as needed. Or they may fall short as the BPH worsens.

When drug therapy no longer helps, men may start to wonder about surgery to trim away some of the overgrown tissue inside the prostate gland and restore urinary flow. But before exploring that route, make sure to give medication a fair chance to work, says Dr. Michael J. Barry, a clinical professor of medicine at Harvard Medical School who helped write national guidelines on how to treat BPH: "Make sure the drug therapy is optimal, confirm the diagnosis, and then you might consider more invasive therapies."

Give medication a chance

Doctors use two classes of drugs to treat urinary symptoms attributed to BPH: alpha blockers and 5-alpha-reductase inhibitors (5-ARIs). Here is how they work:

Alpha blockers. These medications relax muscles in the urinary system to ease the flow and reduce sudden and frequent urges to empty your bladder. The dose of an alpha blocker is stepped up gradually as you remain watchful for side effects, such as nasal congestion or headache. "The ideal is to get to the most effective dose without bothersome side effects," Dr. Barry says.

The older alpha blockers doxazosin (Cardura) and terazosin (Hytrin) can cause lightheadedness or fainting from a sudden drop in blood pressure. The newer alpha blockers—alfuzosin (Uroxatral), silodosin (Rapaflo), and tamsulosin (Flomax)—tend not to affect blood pressure.

5-ARIs. If you don't get adequate relief from alpha blockers—and if your doctor confirms that you have an oversized prostate—it may help to add a 5-ARI to shrink the gland. The options are dutasteride (Avodart) and finasteride (Proscar).

As with alpha blockers, you need to give a 5-ARI a chance to work. It will take at least a few months, and perhaps as long as a year. In studies, prostate size decreased by 15% to 20% after a year of treatment. The drugs cause reduced ejaculation volume or low libido in about 5% of men who take them.

Consider other drug options

If alpha blockers and 5-ARIs don't do the trick, you might consider trying tadalafil (Cialis) instead. This drug was originally approved for erectile dysfunction (ED), but is now available in a smaller, daily dose for treating both BPH symptoms and ED.

If you want to try this, be aware that according to the studies done so far, the effect of tadalafil on BPH symptoms is relatively small. Also, its long-term safety and effectiveness are unclear, since the studies have generally lasted only a few months. If you take tadalafil for ED, don't take it with an alpha blocker, because that could cause side effects. And definitely don't take tadalafil if you use nitroglycerin or another nitrate for chest pain.

Confirm the original diagnosis

If you've given the usual drugs for BPH a chance and are not satisfied with the results, consider talking to a urologist to make sure you've been treating the right problem. Sometimes urinary symptoms initially attributed to an overgrown prostate turn out to be caused by muscle spasms in the bladder, known as overactive bladder. The key symptoms are an urgent need to urinate, sometimes accompanied by leaking a small amount of urine, and frequent urination during the day or night.

The urologist may perform extra tests to confirm whether an enlarged prostate or an overactive bladder is the main culprit. If it is the latter, you might try a type of drug called an anticholinergic, used to treat urinary problems in women.

But an accurate diagnosis is a must: if you have obstructed flow caused by an enlarged prostate, taking a drug for an overactive bladder may close off the flow entirely, leading to a medical emergency called acute urinary retention and the need to stick a catheter into the bladder to drain it.

Surgical options for BPH

The most conservative approach to relieve prostate-related urinary symptoms is medication. However, some men may choose to consider surgery early, whether because they don't like taking pills or the pills don't work fast or well enough for them.

Many men have heard of TURP, or transurethral resection of the prostate, which is highly effective and remains the standard against which other treatments are measured. It uses an electrified wire loop at the tip of an instrument, inserted through the penis into the bladder, to trim away excess prostate tissue causing a urinary obstruction.

While TURP remains the mainstay of the surgical treatments for BPH, less invasive treatments are also widely used. One is laser therapy, called photosensitive vaporization of the prostate (PVP). A thin optical ber is inserted through the penis to deliver laser energy to the prostate and shrink it. Typically, patients go home the same day after a laser surgery, even if the procedure is performed at a hospital.

At least six other options are in use besides TURP and PVP. They use small incisions, microwave energy, or electrical current to reduce obstruction of urine flow. Discuss the pros and cons with a specialist.

Many surgical options

Once you have exhausted the nonsurgical options, talk to a urologist about the next step. There are a variety of approaches to clearing a physical obstruction in your urinary system, and the pros and cons should be weighed carefully. Urologists have the most experience in this area and can help lead you to a possible solution.