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 prostates¹¹ or 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.