Aaron Chy, BSc General, PharmD Student
All things in life change with time, and whether we like it or not, our bodies are no exception. For aging men, one of the most common medical concerns that present itself is Benign Prostate Hyperplasia, or simply, enlargement of the prostate, which affects the majority of men between age 55-69, with up to 90% of men having presentations of BPH by age 70.
The extra growth of the prostate seen in BPH is largely considered a product of age and relies on many things including genetics, inflammation, and the production of testosterone in the body. The symptoms of BPH occur when the prostate becomes large enough that it begins to press down on the urethra, blocking the flow of fluid.
The symptoms of BPH tend to vary, but are often minor and are not considered dangerous or life-threatening in any way. They generally include:
- Difficulty starting urination
- Urinary retention
- Post-void dribble
- Inconsistent urinary flow
Cancer risk and PSA testing
Besides the inconvenience that comes from symptoms, the predominant concern among men with BPH is the potential for prostate cancer. Fortunately, the risk of cancer following enlargement of the prostate is significantly low. In fact, the majority of men who exhibit BPH are left untreated unless they exhibit symptoms.
To measure the progress of BPH on the other hand, clinicians used to use a biomarker called Prostate Specific Antigen, which was originally correlated to the incidence of prostate cancer, and thus used as a signal for beginning treatment. However, more recently, there’s been controversy over the usefulness of PSA, and some questions of whether measuring PSA has resulted in over-treatment. Currently, guidelines no longer recommend routine measuring of PSA, though it can still be useful in men between the age of 55 – 69 who believe they’re having symptoms, have a family history or prostate cancer, or present some other reason for concern. (RxTx, Dipiro)
As far as current treatments go, there are two major options for medications to treat BPH:
- Alpha – Blockers
These medications do not reduce the size of the prostate gland but promote muscle relaxation to allow urine to flow out of the bladder. Therefore, they are most appropriate for men experiencing symptoms of BPH, but are at a low cancer risk or do not wish to receive further treatment. Of the alpha blockers, the newer ones, namely Tamsulosin (Flomax®) are often preferred as they do not lower blood pressure as much as older alpha blockers. This is an advantage because it reduces the risks of fainting and falls, especially in older men.
- Testosterone – Reducers
This class of medications acts by reducing the levels of testosterone in the body, thereby reducing prostate size and lowering the risk of prostate cancer. However, they’re considered more invasive as they also come with a number of side effects associated with hormonal changes, namely: sexual dysfunction, reduced libido, and gynecomastia (enlarged breasts). The two medications from this family that are currently used in practice are Dutasteride (Avodart®) and Finasteride (Proscar®). It is not uncommon to see these medications used in combination with an alpha-blocker.
- PDE 5 Inhibitors
Currently, Tadalafil is the only medication from the PDE 5 inhibitor family on the market for BPH. Interestingly, the trade name for Tadalafil is actually Cialis®; however, for treating BPH, Cialis® comes in a much lower dose that’s taken once daily. Similar to alpha-blockers, PDE 5 inhibitors improve symptoms by promoting relaxation; however, they may also provide some benefits in regards to reducing prostate size. Side effects may include headache and dizziness.
Although these medications aren’t used in modern practice as often as the others on this list, anticholinergics prevent muscle contractions around the bladder and are therefore used for individuals who feel they have an overactive bladder. This often occurs after treatment from other medications, or after surgery. Side effects may include dry mouth and sedation. Because of their effects on mental state and alertness, these medications are often avoided in the elderly.
When medications don’t work, there are various surgical options available to either reduce the prostate size or remove it completely. The specific operation performed will vary from patient to patient, but fortunately, they are most often safe and highly successful.
The bottom line
Benign prostate hyperplasia, as the name implies, is a condition characterized by the growth of the prostate gland that is most often non-life threatening. Symptoms, if they do occur, typically involve difficulty urinating and are most frequent in men aged 55 – 69. PSA testing was formerly a method used to measure BPH, but clinicians today largely rely on the presence of symptoms. There are various medical options aimed at addressing either symptoms, prostate growth itself, or both, in addition to surgeries that address the prostate itself. Fortunately, BPH is by-and-large well controlled in the majority of individuals affected by it and is largely considered a minor condition.
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