Medications can treat BPH in men

Q: I have an enlarged prostate gland, which my doctor calls BPH. My symptoms are getting more bothersome, and my wife thinks I need surgery. I'd rather try medications first. What can you tell me about drugs for BPH?

A: The natural enlargement of the prostate that comes with age is called benign prostatic hyperplasia, or BPH. As the prostate enlarges, it starts to press against the urethra, like fingers pinching a straw. This gradually obstructs the flow of urine, forcing the bladder to work harder to push urine through the urethra. Over time, the bladder walls grow thicker, reducing the amount of urine that the bladder can hold.

These changes cause many of the symptoms associated with BPH: a hesitant, interrupted, weak stream of urine; urgency, leaking or dribbling; the feeling that you are not completely emptying your bladder; and more frequent urination, especially at night. Some men also experience urinary incontinence.

Although 50 percent to 60 percent of men with BPH never develop any symptoms, others find that BPH can make life miserable. As a result, many men seek treatment. But talking to your doctor about BPH doesn't mean that you will need surgery. Most doctors recommend medication to alleviate the symptoms of BPH before suggesting an operation.

The FDA has approved two types of drugs for BPH: alpha-reductase inhibitors, including finasteride (Proscar) and dutasteride (Avodart), and alpha blockers, including terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax) and alfuzosin (Uroxatral). In addition to these tried-and-tested medications, some men report benefit from taking saw palmetto or other herbal remedies.

Alpha-reductase inhibitors deal with the "growing" problem by reducing the size of the prostate. They act slowly, taking two months or longer to have an effect. In fact, you may not see the maximum benefit until you've been taking the medication for more than a year. These drugs work best for men with large prostates. (Your doctor can give you a rough estimate of the size of your prostate by doing a digital rectal exam.)

Alpha-reductase inhibitors tend to reduce levels of prostate-specific antigen, or PSA, by about 50 percent. Because PSA can signal the presence of prostate cancer, alpha-reductase inhibitors might hide prostate cancer or delay its detection. As a result, men who choose to have PSA tests to screen for prostate cancer should have a baseline PSA test before using these drugs, and another test six to 12 months later.

Alpha blockers, which originally were approved to treat high blood pressure, deal with the "going" problem by relaxing muscles in the prostate and urinary tract. This relieves constriction of the urethra and allows urine to flow more easily. Alpha blockers help about 70 percent of men with BPH. They reduce symptoms much more quickly than alpha-reductase inhibitors.

Alpha blockers come in two forms: selective and nonselective. Because nonselective alpha blockers (doxazosin and terazosin) also can lower blood pressure, they may not be the right choice for men who take another blood pressure medication. (Taking multiple blood pressure drugs at once can dramatically lower blood pressure, causing dizziness, fainting and other complications.)

The two selective alpha blockers, tamsulosin and alfuzosin, are more specific to the prostate and don't lower blood pressure.

Because the drugs work differently, some doctors prescribe a combination of alpha-reductase inhibitors and alpha blockers. You may need to make several visits to your doctor to determine the appropriate medication and dose. You generally need to take these drugs indefinitely to maintain their benefits. If you stop taking the medication, the symptoms usually return.

Some men have found modest relief with saw palmetto, an herbal supplement, but studies of its effectiveness in treating BPH symptoms have come to opposite conclusions. A 1998 study concluded that saw palmetto supplements could improve urinary symptoms and urine flow about as much as finasteride. But a 2006 study found it no better than a placebo. Even so, many men give saw palmetto a try because it seems to have few side effects.

The drawback to saw palmetto and other herbal products is that their composition and dosage have not been standardized, and the FDA doesn't regulate them. If you decide to use one, tell your doctor so he will be alerted to possible interactions between it and any other medications you take.

In the end, your wife might be right when she says that you will need surgery, because medication doesn't always put an end to BPH. But alpha-reductase inhibitors, alpha blockers and other agents have allowed many men to avoid surgery.

Work with your physician to determine which BPH treatment is the best choice for you.

The Harvard Medical School Adviser is researched and written by the faculty and staff of Harvard Medical School. Visit www.health.harvard.edu/adviser.