Medical Treatments of Benign Prostatic Hyperplasia (BPH)

In this article, Dr. Ivan Schwartzmann, a specialist in Urology, talks about conservative treatment for Benign Prostatic Hyperplasia and pharmacological treatment.

To treat Benign Prostatic Hyperplasia medically, two types of treatment can be carried out: conservative and pharmacological.

Conservative treatment

Many people with Benign Prostatic Hyperplasia (BPH) are not yet in enough discomfort to warrant treatment with pills. Your doctor must rule out possible complications of BPH such as the risk of suddenly being unable to urinate (called acute urinary retention), or the risk of kidney function problems, bladder stones or urinary tract infections, among others.

Most men with BPH who have not presented complications and who have mild symptoms will not need treatment in the following years. In these cases it would be advisable to simply start a follow up or consider certain lifestyle changes such as:

  • Reducing the amount of fluids ingested at certain times, for example, before going to bed or before taking a long trip.
  • Avoid or moderate alcohol or caffeine intake, as they have a diuretic and irritant effect and may increase the amount of urine produced and the frequency of urination.
  • Review baseline medication to improve the type of medications and the time of day they are taken (e.g., treatment with diuretics will worsen voiding symptoms).
  • Treat constipation, as it can worsen urinary symptoms.

Applying these recommendations, alone or in addition to pill treatment, has been shown to help improve symptoms and also help prevent disease progression.

Pharmacological treatment

In case the symptoms or the risk of complications cannot be controlled with lifestyle changes, pharmacological treatment, i.e. pills, should be initiated. The different treatments will be differentiated by the type of symptoms to be treated and the origin of these, as well as by the size of the prostate and the characteristics and preferences of each patient.

  • Alpha blockers (or alpha-adrenergic blockers).

The main ones are: Alfuzosin, Doxazosin, Terazonsin, Tamsulosin, Silodosin.

Their function is to relax the prostate muscles and allow urine to flow more easily through the prostate, but they do not reduce the size of the prostate. They are most effective in small prostates, i.e. less than 40 cc. In long-term studies, they do not reduce the risk of acute urinary retention (sudden inability to urinate) or the need for surgery. No differences in effectiveness have been observed between the different types of alpha blockers, so it is not recommended to switch from one type to another if the first has not been effective.

As for adverse effects, the most frequent are dizziness, orthostatic hypotension (dizziness on rising) and tiredness. Normally they do not affect sexual function (erections, sexual appetite), but they do produce an alteration in ejaculation, which consists of no semen coming out when ejaculating. The semen usually goes into the bladder and then comes out with the urine. This is known as retrograde ejaculation.

  • 5alpha-reductase inhibitors (5ARI)

There are two types of 5ARIs: finasteride and dutasteride.

These drugs exert their effect by reducing the size of the prostate. They reduce the level of prostate-specific antigen (PSA) in the blood by approximately 50% after a 6-month treatment. They exert their effect very progressively and the maximum effects on the way of urinating are observed after 6 months of treatment. They tend to be most effective in prostates over 40 grams. 5ARIs do reduce the risk of acute urinary retention and reduce the need for prostate surgery in the long term.

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Their most frequent possible adverse effects are: decreased sexual appetite (libido), erectile dysfunction and, to a lesser extent, alterations in ejaculation. In some rare cases, inflammation of the breasts (gynecomastia) may also occur.

  • Antimuscarinics (Anticholinergics) and Beta-3 agonists

They are drugs aimed at the so-called bladder filling symptoms, which we explained in the previous article. They act by controlling bladder contraction, they do not act on the prostate. The most frequent side effects of antimuscarinics are dry mouth, constipation and difficulty urinating. Beta3-agonists produce less dry mouth and constipation compared to patients treated with muscarinic receptor antagonists, but are contraindicated in patients with poorly controlled severe hypertension.

  • Phosphodiesterase-5 Inhibitors (PDEI5)

The most famous of this family is Viagra, but the only one accepted, for the moment, for the treatment of lower urinary tract symptoms secondary to BPH is tadalafil 5 mg per day. It improves urinary symptoms and erectile function. A good option in patients with BPH and ED, but they are more expensive and are not usually covered by social security.

Their main side effects are: facial flushing, headache and gastric discomfort. In addition, they are contraindicated in patients with severe heart problems, among others.

  • Phytotherapy – Plant Extracts

Phytotherapy or herbal medicines include roots, seeds, pollen, bark or fruits. The mechanism of action in the patient (in vivo) of these types of preparations is not entirely clear. Extracts of the same plant produced by different companies and even different batches from the same company may contain different concentrations of the active ingredient. So the treatment effect may be difficult to predict.

Only Serenoa repens extracted with hexane has been recommended for well-established use by the European Medicines Agency.

  • Combination treatment

Depending on the symptoms presented by the patient or the response to an initial treatment, a combination of drugs may be offered. The most studied and most frequently used combinations are:

  1. Combination of alpha blocker and 5ARI: has been shown to be superior to each of these drugs individually, when indicated.
  2. Combination of alpha blocker and anticholinergic: has proven to be effective and safe in the treatment of patients with bladder filling and emptying symptoms, i.e., those with both prostate-caused urine outflow obstruction and bladder overactivity.

Other drug combinations do not have as much scientific evidence and their use is at the discretion of each urologist and the patient’s preferences.

What happens when medical treatment fails?

If the medical treatment is not effective from the beginning, if it loses effectiveness over time, or if the side effects are not well tolerated by the patient, surgical treatment should be considered, which we will discuss in the next article.

If you have any doubts about the treatment you are following, discuss it with your doctor and NEVER change your medication on your own initiative.