Benign prostatic hyperplasia: A new look at an old operation

Benign prostatic hyperplasia (BPH) is an important cause of distress in older men. It can produce urinary frequency and urgency as well as a slow urinary stream, dribbling, and incomplete emptying of the bladder. BPH is also an important cause of nocturia — nighttime urination. The symptoms begin to mount as men enter their 60s, and they continue to increase as the prostate continues to enlarge over time. By the age of 80, about 25% of all men have BPH that is bothersome enough to require treatment, and countless others have mild symptoms they can "live with." In all, an estimated 5.5 million American men have clinically significant BPH, and about two million seek medical help for their symptoms every year.

Treatment options

Until recently, men who asked for help got it in the form of an operation devised more than 75 years ago, the transurethral resection of the prostate (TURP). As recently as 1995, about 400,000 TURPs were performed in the United States each year. Since then, however, the number has declined dramatically, even though doctors still view it as the "gold standard," the surest way to relieve symptoms of BPH. The decline hasn't been triggered by any problems with the operation itself — it's actually gotten better and safer — but by three important developments:

  1. A new understanding of the natural history of BPH. In the past, many men underwent TURPs principally to prevent serious complications, such as acute urinary retention. But doctors have learned that major complications are relatively infrequent, and that they can often be predicted in time to schedule surgery when it's really needed. As a result, men are now encouraged to decide for themselves about treatment, moving ahead only if they are significantly bothered by their symptoms despite lifestyle adjustments.

  2. New medical treatments. Until 1992, when a man asked to be treated for BPH, he was asking for a TURP. All that changed when the FDA approved medication for BPH. Most men experience improvement with prescription drugs such as alpha blockers and finasteride, or herbs such as saw palmetto (see box).

  3. New surgical procedures. Although medications help about 70% of men with BPH, a TURP usually provides superior relief. When Harvard's Health Professionals Follow-up Study compared the symptomatic benefits of alpha blockers, finasteride, and TURP, it found that surgery was the most effective. Unfortunately, surgery also had the most complications and side effects, which triggered an explosion of "less invasive" surgical techniques. Laser surgery is among the most promising, but there are others (see "Minimally invasive treatments," below). The FDA approved laser treatments for BPH in 1998. Variations on the theme are being introduced at a staggering pace, and experience is still limited, particularly with regard to long-term results. Still, many men are attracted to laser surgery in the hope that it will be nearly as effective in reducing symptoms but will produce fewer side effects.Sexual dysfunction is a common concern for men facing surgery for BPH — but are sexual complications really less common after laser surgery than TURP?

Medication for BPH

While surgery is the most effective therapy, men who are bothered by symptoms of BPH can consider three types of medication, which can be used singly or in combination.

Alpha blockers relax the muscles in the prostate and bladder neck, easing the flow of urine in about 70% of men with BPH. Doxazosin (Cardura) and terazosin (Hytrin) are usually taken at bedtime. Because both can lower the blood pressure, doctors usually start with a 1-mg dose and gradually increase it to a maximum of 8 mg (doxazosin) or 10 mg (terazosin). The newest alpha blockers as of mid-2005, tamsulosin (Flomax), and alfuzosin (Uroxatral), are less likely to affect the blood pressure. The usual dose of tamsulosin is 0.4 or 0.8 mg taken 20 minutes after the evening meal, while the 10-mg dose of alfuzosin, which is less likely to cause retrograde ejaculation, is taken right after a meal.

Unlike the alpha blockers, finasteride (Proscar) and dutasteride (Avodart) actually shrink the prostate gland. Unfortunately, they take many months to work and are likely to help only men with rather large glands. The usual dose is 5 mg a day for finasteride, 0.5 mg for dutasteride. Both lower prostate-specific antigen (PSA), sometimes complicating screening for prostate cancer, and they cause reversible erectile dysfunction in a small percentage of men.

Herbs can also help some men with bothersome BPH. The best studied is serenoa repens, better known as saw palmetto. Because it is sold as a dietary supplement, it is exempt from FDA standards for purity, efficacy, and safety. But many clinical trials, conducted mostly in Germany, suggest that it can reduce the symptoms of BPH with few side effects.

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