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Medical Treatments for BPH

Posted Aug 24 2008 1:49pm
PAUL MONIZ: I'm Paul Moniz. Thanks for being with us. If you have an enlarged prostate, you know it can be miserably uncomfortable turning routine urination into a chore. While little can be done to prevent your prostate from enlarging, it is part of the aging process for most men, there are medical treatments available to alleviate symptoms of BPH, or Benign Prostatic Hyperplasia.

Here to tell us about those treatments are two urologists. We have Dr. Christopher Dixon. He is an Assistant Professor of Urology at the NYU School of Medicine. He is also the co-director of the Prostate Center at NYU. Dr. Dixon, thanks for being here.

We also have Dr. Robert Salant, a Clinical Associate Professor of Urology at the NYU School of Medicine. He is also affiliated with Beth Israel Medical Center, Cabrini Medical Center and Hospital for Joint Diseases, all in New York City.

Dr. Salant, even before surgery is considered, there are patients or even before medicines are considered, I should say, there are patients who don't even want to take that. What can be done before medicines are put into the line of therapy here?

ROBERT SALANT, MD: Once a diagnosis of a prostatic enlargement is made, basically your treatment will depend upon the level of symptoms. For men who have enlarged prostates with minimal to mild symptoms, you may treat them with what we euphemistically call "watchful waiting." This is basically just keeping an eye on their symptoms, having examinations on an annual basis, and seeing how the symptoms change over time.

We have here a symptom score sheet which is a seven-question questionnaire that is self-administered, that the patient fills out and gives the urologist subjective information on how the patient is urinating and how the symptoms are interfering with the patients lifestyle. Th last question is actually a question related to the quality of life. Here the patient will tell us how much his symptoms are bothering him.

You may have two patients with very similar symptoms, one of whom is quite comfortable with the symptoms, the other who absolutely needs to be treated.

PAUL MONIZ: From this you can determine a course of action in addition to diagnostic tests and digital rectal exam. You could do a digital rectal exam on someone, find an enlarged prostate but that person may not have any symptoms. Is that right?

ROBERT SALANT, MD: Correct. Size is just one factor that goes into the constellation of symptoms that can create problems for the patient. Having an enlarged prostate and having a very enlarged prostate does not necessarily correlate with the amount of blockage or obstruction that the patient will experience.

PAUL MONIZ: Now we should add that that digital rectal exam should begin at age 40 yearly for all men, right?

ROBERT SALANT, MD: Yes.

PAUL MONIZ: And generally, that is for prostate cancer screening.

ROBERT SALANT, MD: The rectal examination does a few things one of which is to screen for prostate cancer which is an absolute. That must be done once a year starting at the age of 40. The other thing it does is give the urologist a handle on the size of the prostate which can be followed over time. You can see if there has been a significant change. Certainly prostate cancer screening is the most important thing.

PAUL MONIZ: Dr. Dixon, at which point do you begin medical treatment and we should add that prostate enlargement has nothing to do with prostate cancer. Is that correct?

CHRISTOPHER DIXON, MD: The two conditions, cancer and BPH (benign prostatic hyperplasia) are really two separate processes that can occur in the same prostate for that matter. The decision to treat, I think, sort of steps back may be one or two steps. If the symptoms have clearly been diagnosed to be caused from this process of BPH, then the next question which is really tossed back to the patient, as it were, is how bad are those symptoms. Do those symptoms bother you on a daily basis? The question that I usually put to my patients directly is "Do those symptoms bother you enough to consider taking a pill once a day indefinitely assuming that the pill is obviously going to make those symptoms better and not cause you any side effects. This is what sort of leads us down the road towards medical therapy which is usually the most appropriate therapy for the vast majority of patients. There are some patients, obviously, who go beyond medical therapy or who present with some of the more extreme conditions of BPH. These are urinary retention where they can't urinate or some of these more severe, purely medical problems. But the vast majority, 85-90% of patients really are seeking an evaluation because they're annoyed really on a day-to-day or night-to-night basis.

PAUL MONIZ: Dr. Salant, what kinds of medicines are available?

ROBERT SALANT, MD: In general, there are two classes of medication that can be used to treat symptomatic enlarged prostate. One class is known as the alpha-blockers. These are medications that don't actually shrink the prostate. They relax the prostate. If you were to look of what a prostate is made out of, about 40% is made up of smooth muscle and connective tissue. The way these medications work is to relax the smooth muscle. What that will do is reduce the amount of resistance that the bladder has to push with to get the urine out of the bladder. So these medications make the urinary process easier by reducing the resistance to urine flow.

There is another class of medications called the 5-alpha reductase inhibitors which are medications which actually do shrink the size of the prostate. These medications work slowly over time and they can actually reduce the size of the prostate and hopefully improve the symptoms because the prostate is small.

PAUL MONIZ: You have a diagram to show us at least on the top that can go through how the shrinking medication might work, finasteride as it's called.

ROBERT SALANT, MD: This is a diagram of prostate and it's broken into two halves. The left half is what a normal prostate would look like and you have the prostate surrounding the tube called the urethra and that's the tube that transports the urine from the bladder on out through the body. When the prostate starts to grow from BPH, nodules of tissues grow around the urethra from within. It's not a uniform enlargement of the prostate as one might expect. What the medications that shrink the prostate do is actually to shrink these nodules of tissues, decreasing the size of the prostate.

The other medications, the alpha-blocker medications, actually relax the smooth muscle component of the prostate taking the pressure off of the urethra and allowing for easier urine flow.

PAUL MONIZ: How do you know which to prescribe?

ROBERT SALANT, MD: In general most commonly people start with an alpha-blocker. The reason for that is the alpha-blockers have been shown to work in the majority of patients who have symptomatic BPH regardless of the size of the prostate. The medications that shrink the prostate work better for men who have significantly enlarged glands. As we mentioned before, size is just one factor that creates the symptom of prostate blockage. A man could have a prostate that is only minimally enlarged but yet have significant symptoms. In a patient like that shrinking the prostate probably won't do a lot of good because it's not the size that's contributing to most of the symptoms. The alpha-blocker therapies would have a more beneficial effect.

PAUL MONIZ: Dr. Dixon, what about the side effects of these drugs?

CHRISTOPHER DIXON, MD: They are very well studied both alpha-blockers and finasteride and the data is fairly clear. The alpha-blockers, I think, have a very set side effect profile. Side effects, in general, are not very severe. They're not terribly common although if you look at large trials, probably around 15 or so percent will withdraw because of side effects. So it is not something that you can ignore.

The alpha-blockers typically if they have side effects at all will be things like fatigue, some little light-headedness or dizziness. These types of side effects.

In the case of the 5-alpha reductase inhibitors, the finasteride, those therapies that reduce prostate size, they typically work through a hormonal type mechanism. Their side effects also are quite rare. Both classes are reversible which is discontinuation of the drugs.

In the case of a finasteride type therapy, usually the side effects you'll see, if they occur, relate to sexual function. They include diminished libido, perhaps diminished erections and perhaps decreased ejaculate fluid volume. Things like this.

PAUL MONIZ: That could a significant side effect.

CHRISTOPHER DIXON, MD: Certainly for some men that is enough certainly to withdraw that therapy. But it's a relatively low incidence, perhaps 5% or so. I don't think someone should refrain from using that drug when it's appropriate just because of a relatively low risk of a side effect that's completely reversible should you discontinue the drug.

PAUL MONIZ: Dr. Salant, what about the long-term safety of these drugs? Because taking these types of medications in both classes is an indefinite proposition, is that right?

ROBERT SALANT, MD: These drugs are all designed for chronic use. Before initiating the therapy, you really need to discuss that issue with the patient. There are some patients who really do not want to take medication for the rest of their lives. They would either have no treatment or seek an alternative treatment.

In terms of their long-term safety, as far as the drugs have been studied and they have been studied for well over -- the alpha-blockers have been studied for well over 10 years -- there is really no significant long-term downside from taking the medication.

PAUL MONIZ: A question about finasteride for those in our audience who may have heard it before. Finasteride is also used in another drug called Propecia which is five times weaker than the Proscar, then the finasteride used for this treatment. What is the correlation? If someone is taking finasteride for hair loss in a weaker formulation, is there any benefit perhaps long term as a preventative for their prostate or are the concentrations so weak that it wouldn't help?

ROBERT SALANT, MD: That's an issue that's actually being studied right now. Nobody has the definitive answer. Certainly the one-milligram dose, which is one-fifth of the dose that is often used for treating enlarged prostates, may have some effect on the prostate itself. What we do know is that the lower dose found in Propecia has less of the side effects in terms of difficulty with erections and difficulty with volume of ejaculate.

PAUL MONIZ: But what you don't know is if it would be truly effective in shrinking the prostate.

ROBERT SALANT, MD: Right. These medications have not been studied to see whether or not they can prevent prostate growth.

PAUL MONIZ: Dr. Dixon, what about some of the anecdotal evidence that you have from talking to your patients. I mean you see patients all the time. They come in. They take the medication. How radically altered can their urinary habits be?

CHRISTOPHER DIXON, MD: I think the quality of life can be drastically improved. I think you have to put the medical therapies in perspective in terms of all treatments that are available. Generally speaking, there are three or four therapies that one would think of. They are watchful-waiting, medical therapies, minimally invasive approaches and then standard surgical approaches.

I think the expectations from a pill should really not be confused with the expectations of a standard surgical procedure which is generally considered as the most beneficial in terms of therapeutic improvement.

On the other hand, if you're sitting there with a patient (as we do) on a daily basis and you say, "Well, would you rather try a pill to improve your symptoms and see if this gives you personally enough symptomatic relief to make your quality of life what you would like it to be? Would you rather take a pill or go try an operation? It's a very easy answer for patients to pick. The pill obviously always comes out on top. I think that's a very rational approach.

Symptoms are not bothersome enough to go towards surgical intervention, but they can have dramatic relief and improvement in quality of life with mild, moderate or severe symptoms with an alpha-blocker. It will typically work very quickly in a matter of a few days in some cases, at the very longest, two to four weeks probably. They can perceive and see an actual benefit right then and there.

I think the finasteride therapy is probably much less impressive that way. This has been, I think, fairly well established that even though it will shrink the prostate on average 20-21% after six months or so, that does not necessarily correlate or translate into a patient with a better quality of life. This head-to-head comparison has been done in very well controlled, well designed trials. It's pretty clear, I think that for symptom improvement, which is what drives people, alpha-blockers, I think lead the way.

PAUL MONIZ: Dr. Salant, what about drug interactions? Since this is a condition that effects man who are traditionally older, they may already be on other medications for different conditions? Do these medications mix okay with other medications that they might be taking generally?

ROBERT SALANT, MD: You're right in that many of the men who suffer from symptoms of prostate enlargement are in the older population. They tend to have other medical conditions, including high blood pressure, heart disease, diabetes, and lung diseases. The alpha-blockers have a side effect of lower blood pressure which accounts for some of the side effects that Dr. Dixon spoke about earlier. The interaction of the alpha-blockers with other antihypertensive medications can be problematic. In those cases, you have to use the medications judiciously. Start with very low doses and slowly titrate or increase the dosing level to a therapeutic level.

The finasteride medications have significantly fewer interactions with other medications. They work more slowly than the alpha-blockers do and are very well tolerated.

PAUL MONIZ: Okay. Thank you very much, Dr. Robert Salant of NYU and also Dr. Christopher Dixon of NYU as well.

Again, if you are experiencing urinary symptoms, you should seek the advice of your urologist who may prescribe some of the medicines that are available.

I'm Paul Moniz. Thanks for being with us.

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