TWO weeks ago, we spoke about the urinary symptoms that taxi driver John experienced.

His urinary symptoms were significantly bothersome and affected his quality of life. He sought medical attention for relief of his symptoms. We will now speak about the medical management of benign prostatic enlargement.

Treatment options

The treatment options for an enlarged prostate include watchful waiting, medications, minimal invasive and open or robotic-assisted surgery. The best choice for treatment depends on the size of the prostate, age and medical fitness of the patient, and presence of complications of the enlarged prostate.

The medical management of an enlarged prostate has been a standard of care since the 1990s, when robust clinical trials demonstrated that medications not only subjectively improved lower urinary tract symptoms, but also objectively improved urinary flow rates. Currently, there are three major groups of drugs used in the treatment of a benign enlarged prostate. The primary aim of these agents is to improve urinary flow rate.

Alpha blockers are a group of drugs which relax the muscle at the bladder neck and within the prostate. They provide relief of symptoms within a week and improve urine flow. The drugs also prevent the progression of urinary symptoms that would occur based on the natural history of an enlarged prostate. These drugs are best administered to men with moderate to severe bothersome symptoms.

Common agents prescribed are Tamsulosin (Flomax, Urimax, Tamsol, Veltam), Terazosin (Hytrin), Doxazosin (Cardura), and Silodosin (Silorel). Tamsulosin is perhaps the most frequently prescribed agent worldwide.

The alpha blockers are not only effective, but also well-tolerated. Some patients may complain of the side effects of dizziness and mild lowering of the blood pressure. An important effect of these drugs is the absence of semen at the time of orgasm during intercourse. This is due to a condition called “retrograde ejaculation”, where the semen enters the bladder instead of going down the urethra at the time of orgasm.

Patients who are treated with these drugs and are scheduled to undergo cataract surgery should advise their ophthalmologist because these drugs may cause a complication which makes this surgery technically difficult.

5-alpha reductase inhibitors are a group of drugs which block the conversion of testosterone to dihydrotestosterone (DHT). As previously mentioned, the hormone DHT is one of the agents responsible for the growth of the prostate. Reduction of this hormone causes the prostate gland to shrink. The agents prescribed are Finasteride (Proscar) and Dutasteride (Avodart).

These agents also prevent the progression of lower urinary symptoms in patients with enlargement of the prostate. Since their introduction, they have drastically changed the natural history of an enlarged prostate reducing the need for surgery in many of these patients. As opposed to the alpha blockers, these agents may take up to six months to be effective. There are potential undesirable side effects with their use. These include reduced desire for sex, erectile and ejaculatory dysfunction.

Both groups of drugs may be prescribed as a combination for their complementary actions. For example, Tamsulosin and Avodart are frequently prescribed together in an individual patient. A single drug called Duodart represents a combination of Avodart and Tamsulosin in one capsule, and is frequently prescribed. These agents are available in Jamaica and subsidised by the National Health Fund.

Tadalafil (Cialis) is popularly known as a drug used to treat erectile dysfunction, but a low dose taken daily can treat the symptoms of an enlarged prostate. The mechanism of its action in both diseases is based on its action to increase nitric oxide. This drug may also be combined with Avodart. Potential side effects include headache, stomach and muscle pain, stuffy nose, and dizziness. The benefit of Tadalafil is its ability to treat both lower urinary tract symptoms and erectile dysfunction by administering one oral agent.

Medications do not work in all patients and when this occurs, surgery is suggested. We will discuss surgery to treat prostate enlargement in the next issue.

Dr Belinda Morrison-Blidgen is a consultant urologist and senior lecturer at The University of the West Indies. E-mail her at Belinda.morrison02@uwimona.edu.jm