Choosing a Treatment

Are there any medicines that can help symptoms due to an enlarged prostate?

Rather than an operation, drugs, such as alpha blockers (e.g. tamsulosin, Flomax, Omnic, alfuzosin, Xatral, Cardura), relieve prostate symptoms by relaxing the muscle of the prostate and are useful in some patients with BPH, especially younger men with milder symptoms.

Finasteride or dutasteride can reduce the size of the prostate, and improve symptoms in about 30 percent of patients who take it. However, drugs have to be taken for the rest of your life in order to remain effective.

Using finasteride and an alpha-blocker together is more effective than either drug alone to relieve symptoms; they prevent BPH getting worse. The two-drug regimen reduced the risk of BPH getting worse in two out of three patients, compared to one-in three for an alpha-blocker alone and one in three for finasteride alone.

Drugs or medicines may not be enough, and more effective treatments such as TUNA, TURP or GreenLight PVP may be necessary.

Should I have an operation?

At one time, BPH was invariably thought to be a progressive disease. That is no longer the case. Only about 40 to 50 percent of all men with BPH actually develop any symptoms due to this condition, and of that number, only a proportion will need prostate surgery.

BPH requires treatment only if the symptoms are severe enough to disrupt your life or threaten your health. If, during your prostate examination, your doctor finds that you have significant symptoms and that your prostate gland is enlarged, you may start a program of medication and changes in life style to improve your symptoms. During this time, your doctor may examine you periodically and ask you to complete questionnaires (e.g. IPSS).

If your urination problems are not adequately relieved by medication or the side effects of the drug are excessive, you might then consider TUNA, a TURP or Greenlight PVP. TUNA is the least invasive of all treatments and Greenlight PVP utilises a laser to remove prostate tissue. With surgery for BPH, only the enlarged tissue that is pressing against the urethra is removed; the rest of the prostate is left intact. Removal of the enlarged part of the prostate is the best long-term solution for patients with BPH. Surgery usually relieves the obstruction and incomplete emptying caused by BPH more than any other treatment.

For certain patients with particular signs and symptoms, a TURP or laser prostatectomy is almost always recommended. These signs and symptoms include:

  • Total inability to urinate
  • Profuse bleeding through the urethra due to prostatic enlargement
  • Difficulty emptying the bladder because of prostatic obstruction, which can lead to progressive kidney failure
  • Recurrent urine infections

If you decide to have a prostatectomy for reasons of comfort or for a more severe indication, you should know that an operation offers the greatest chance of getting rid of your symptoms.

Are there any alternatives to TURP or laser prostatectomy for BPH?

TUNA is a good minimally invasive treatment for prostate enlargement. It has advantages over traditional surgery in that it is less invasive and does not affect ejaculation. A stent is another alternative, but this is usually reserved for older men for whom a surgical procedure is particularly risky.

What are the risks/benefits of surgery?

Although there are nonsurgical treatments available to treat BPH, an operation offers the highest chance of alleviating prostate problems. However, it also can result in problems either during or after surgery.

After a TURP or laser prostatectomy, some men will find that semen does not go out of the penis during orgasm. Instead, it passes into the bladder and is passed with the urine next time. The feeling of orgasm stays the same. This backwards ejaculation is a problem for couples who want to have a baby.

Some conditions after TURP or laser prostatectomy may require additional treatment including:

  • impotence (small risk)
  • uncontrolled urine leakage i.e. incontinence (very small risk)
  • a constriction of the urethra (stricture); or the necessity of a second operation later, in some patients (10%).

These risks and benefits must be considered by anyone considering a prostate operation, and your doctor can help you make your decision.

What tests are there to help decide what treatment is necessary and appropriate?

These tests include the following, but do not necessarily have to be performed always:

  • Urinary symptoms (IPSS) questionnaire: This quantifies the severity of the symptoms and how much bother they cause.
  • Blood test: for kidney function and to estimate the size of the prostate, and risk of prostate cancer (PSA)
  • Urine Chemical Analysis: to determine the presence of blood or evidence of infection
  • Urine Flow Rate: you will be asked to pass urine into a special machine that measures the speed of your urine flow as well as the volume of urine expelled. This test helps in evaluating the function of your bladder and the degree of prostatic obstruction.
  • Measurement of the urine left in the bladder after passing urine (postvoid residual): The volume of urine in the bladder after it has been emptied can be measured by an ultrasound scan. If this is increasing over time, then surgery is probably a good idea
  • Transrectal ultrasound measure of prostate volume: A probe is inserted in the back passage (rectum) and the size of the prostate is accurately measured. The larger the prostate, the greater the chance of problems in the future.
  • Urodynamics: Measuring pressure in the bladder during urination can determine how strongly the bladder contracts, the extent of obstruction by the prostate, and whether the bladder contracts inappropriately when it is filling with urine. This test also is done by placing a small catheter in the bladder and rectum.
  • Cystoscopy: To look at the configuration of the prostate and changes in the bladder that may be responsible for urinary symptoms.

 

How do I decide what treatment is necessary?

You can predict your chance of being completely unable to pass urine or needing surgery over 6 years by going to the following website (www.oncovance.com). If you register, you then need to know your age, IPSS score (also known as AUA SI) and PSA. Further information can be entered, if you have it, to improve the accuracy.

Mild and non bothersome urinary symptoms

If your urinary symptoms are mild (ie IPSS less than or equal to 7 out of 35) and do not cause bother (bother score less than 3 out of 6), then only changes in lifestyle are usually all that is necessary especially if the prostate is small, the PSA is less than 1.5 ng/ml and the bladder empties efficiently. If necessary medication such as an alpha blocker may be given to reduce symptoms. A 5 alpha reductase inhibitor may shrink the prostate over time and reduce the chance of significant problems in the future. Surgery is not usually suggested if the symptoms are mild and respond well to alpha blockers.

If biopsies of the prostate have been taken and inflammation of the prostate was found, there is a greater chance that there may be more problems with either a complete blockage (acute urinary retention) or that surgery may be needed in the future. As such, it is probably sensible to take a 5 alpha reductase inhibitor (e.g. finasteride or dutasteride) as these can reduce the probability of these undesirable outcomes.

Moderate and bothersome urinary symptoms

If the symptoms are more moderate (IPSS between 8 and 19 out of 35) and bothersome (bother score 4 or more out of 6), then treatment by either drugs (alpha blockers), TUNA, laser prostatectomy or traditional TURP is usually effective. If alpha blockers have not worked well or the bladder is emptying less well over time, then surgery is recommended.

When drugs are used, it's better to use a combination of alpha blockers with finasteride or dutasteride especially when the prostate is large or the PSA is greater than 1.5 ng/ml.

Transurethral needle ablation (TUNA) is a minimally invasive procedure performed as an outpatient. There are many advantages of TUNA including the preservation of normal ejaculation and sexual function. However, about 4 in 5 men find the treatment still works after 5 years. There is less long term evidence for its use compared to a traditional TURP.

The GreenLight PVP laser prostatectomy and TURP are more effective than drugs. In general, Greenlight PVP laser prostatectomy and TURP are most likely to be effective if the prostate is causing obstruction of the bladder. This can be determined by the tests listed above.

Severe and bothersome urinary symptoms

For severe urinary symptoms (IPSS 20 or more) that are bothersome (4 or more out of 6), it is important to look in the bladder to make sure there are no other problems. Further tests to determine whether urinary symptoms are due to obstruction by the prostate will often be necessary, especially if a TURP or other surgical procedure is being considered. The biggest improvement in symptoms and quality of life occurs with the GreenLight PVP or TURP, but not everyone wants these procedures. Medicines such as alpha blockers or finasteride/dutasteride also relieve symptoms, but not as much. If drugs are used alone, further treatment is necessary. A poor response to alpha blockers and increasing residual urine or symptoms mean that surgery is almost always necessary.

In addition, if surgery is delayed when the bladder is obstructed by the prostate, the benefit of surgical procedures may be less than when surgery is performed early. This is possibly because the bladder may undergo irreversible changes if it is blocked for a long period of time. With less invasive treatments available now (eg TUNA or GreenLight PVP laser prostatectomy), it may be better to opt for one of these earlier than later.

How do I decide between drugs or surgery?

Conservative treatments and drugs such as alpha blockers work best when symptoms are mild or moderate. TUNA gives symptom relief as a minimally invasive procedure that preserve normal sexual function. If symptoms are severe and the prostate is causing a blockage, then GreenLight PVP or TURP surgery is more effective and lasts longer than TUNA or drugs.

The severity of symptoms is judged best by assessing the symptom score (IPSS). If the symptom score is 20 or more and the symptoms are bothersome (4 or more). A test called urodynamics can determine if there is a blockage or not, and can also tell if the bladder contracts at the wrong time. Sometimes, urinary symptoms such as getting up at night or having to rush urgently to pass urine are not due to the prostate; these symptoms may be due to the bladder contracting inappropriately. Urodynamics can help predict if the GreenLight PVP or TURP may help. The GreenLight PVP or TURP is most effective when there is obstruction present and this is usually proven by urodynamic testing.

Other factors are also important such as general fitness. It may not be safe to have an anaesthetic, which is necessary for a TURP or GreenLight PVP. Drugs may be the only treatment possible. Occasionally, other procedures are also possible such as 'stents'.

What do I do about having to get up at night?

Getting up at night and passing urine becomes more common as one gets older. Surgery on the prostate may help if the bladder is not emptying completely because of obstruction. However, the prostate is not always the cause of getting up at night. Usually, urine production stops at night, but this may not occur resulting in excess urine production at night. To detect this, keep a record of the total amount of urine passed during the day and night. If the amount of urine made at night is more than 25% of the total daily amount, then the following can help, but discuss with your doctor before adopting the advice below:

  • stop drinking 4 or more hours before going to bed
  • take a nap in the afternoon making sure the legs are elevated and the body is horizontal if possible.
  • wear tight compression leg stockings during the day

Your doctor should advise you further.

Drugs such as alpha blockers (eg tamsulosin or alfuzosin) can also be of benefit. These measures can be combined with a tablet to help encourage more urine production in the afternoon (a diuretic) and something to stop urine production at night (DDAVP). 

In some cases, the urgent need to pass urine occurs during the day and night. This problem may be due to overactivity of the bladder muscle and can be helped by avoiding caffeine and taking medicines. These medicines include solifenacin (Vesicare), tolterodine (Detrusitol) and oxybutynin (Lyrinel).