Benign Prostate Hypertrophy (BPH) Urological Management


Email Raji.Kooner@svha.org.au or call 02 8382 6980 for a confidential appointment.

It’s important to tell some patients that they don’t have cancer with BPH, so we make an assessment and maybe that’s why they’re presenting1.

So, essentially our management is dependent on the troublesome-ness or bothersome-ness of these symptoms.

If patients are not bothered, and they’re reassured, then they don’t need to have any subsequent treatment2.

If they have mild to moderate symptoms we might consider medical therapy2, and medical therapy can be divided into three categories.

Firstly, there are alpha blockers. These agents relax the neck of the bladder and the prostate, and allow patients to pass urine better.

Usually, patients have to be on these lifelong for them to be effective3.

They take about two weeks to work, and there are a number of agents that are available4.

There is a prescription medication agent that’s available through the government health scheme, but unfortunately it has side effects as it’s a blood pressure medication5.

There are some selective agents (prescription medication), which are more selective for the prostate, and allow us to treat the obstruction with less side effects6.

Unfortunately, they’re not subsidised by the government.

It’s important to remember also that 20% of patients get better by themselves7, so if they start on these medications, they do need to cease them at some stage to see if their symptoms are better, and if they are they don’t need to restart them.

The side effects are mainly dizziness or lightheaded-ness8. Some patients get retrograde ejaculation with the semen going back into the bladder when they ejaculate, but that’s reversible when the medications stop8.

That’s usually my first line of medical therapy.

The second medical therapy is 5-alpha reductase inhibitors. They inhibit the transfer of testosterone to dihydrotestosterone. They lead to shrinkage of the prostate, they take three months to work. They do have some side effects, occasionally erectile dysfunction, occasionally gynecomastia, swelling of the breasts9.

There is some concern that this agent may increase the instance of more active cancers10, and so we’re sometimes reluctant to start this, but it is useful in patients who have particularly large prostates11or maybe recurrent bleeding from the prostate.

The third type of treatment is herbal treatment. There are some studies that have shown that this is efficacious, agents such as Serenoa or Saw Palmetto, but a study in The Lancet12 where they combined all these studies together showed that there was probably no additional benefit, but some patients on these agents do report benefit, and do continue to use them13.

So they’re the conservative measures for benign prostatic enlargement.

References

1. Prostate Enlargement (Benign Prostatic Hyperplasia) - NIH - https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-problems/prostate-enlargement-benign-prostatic-hyperplasia
2. AUA Guideline on Management of Benign Prostatic Hyperplasia (2003). Chapter 1: Diagnosis and Treatment Recommendations - Journal of Urology - https://doi.org/10.1097/01.ju.0000078083.38675.79
3. BPH: Treatment Helps Men Cut Down on Frequent Bathroom Trips - Urology Care Foundation - https://www.urologyhealth.org/healthy-living/urologyhealth-extra/magazine-archives/spring-2018/bph-treatment-helps-men-cut-down-on-frequent-bathroom-trips
4. Herbert Lepor - Alpha Blockers for the Treatment of Benign Prostatic Hyperplasia - Rev Urol. 2007 Fall; 9(4): 181–190
5. https://www.nps.org.au/assets/medicines/af6eb5fe-89a5-49ed-b293-a53300fecff7.pdf
6. Kevin T. Rich, Sarah Safranek - Medical Treatment of Benign Prostatic Hyperplasia - Am Fam Physician. 2008;77(5):665-666
7. Overview: Benign enlarged prostate - Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG) - NLM - https://www.ncbi.nlm.nih.gov/books/NBK279204/
8. Zhao-Jun Yu, Hai-Lan Yan, Fang-Hua Xu - Efficacy and Side Effects of Drugs Commonly Used for the Treatment of Lower Urinary Tract Symptoms Associated With Benign Prostatic Hyperplasia - Front Pharmacol. 2020; 11: 658 - doi: 10.3389/fphar.2020.00658
9. MedlinePlus (An official website of the United States government) - https://medlineplus.gov/druginfo/meds/a698016.html
10. B Anitha, Arun C Inamadar, and S Ragunatha - Finasteride-Its Impact on Sexual Function and Prostate Cancer - J Cutan Aesthet Surg. 2009 Jan-Jun; 2(1): 12–16. doi: 10.4103/0974-2077.53093
11. Mayo Foundation for Medical Education and Research (MFMER) - https://www.mayoclinic.org/drugs-supplements/finasteride-oral-route/precautions/drg-20063819?p=1
12. HS Pandha and RS Kirby, PC-SPES: phytotherapy for prostate cancer - The Lancet - https://doi.org/10.1016/S0140-6736(02)09313-3
13. Kristian Leisegang, Mariana Jimenez, Damayanthi Durairajanayagam - A systematic review of herbal medicine in the clinical treatment of benign prostatic hyperplasia - Phytomedicine Plus Volume 2, Issue 1, February 2022, 100153