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- Benign Prostatic Hypertrophy
- Drug Treatment for LUTS in Men with BPE3
- (LUTS) and Diagnosis of BPE3
What is the prostate? The prostate is a gland located in the lower urinary tract, under the bladder and around the urethra (Fig. 1). Only men have a prostate. It produces the fluid which carries semen. The prostate has smooth muscles which help to push out the semen during ejaculation.
A healthy prostate is about the size of a large walnut and has a volume of 15-25 millilitres. The prostate slowly grows as men grow older.
Benign prostatic enlargement Prostate diseases are usually associated with older age. They can cause bothersome symptoms in the lower urinary tract in men over the age of 50. These symptoms may be caused by an enlargement of the prostate, a condition which is known as benign prostatic enlargement (BPE) (Fig. 2). Other conditions can also cause these symptoms and your doctor will take this into account.
Benign prostatic enlargement is a common condition. It is related to hormonal changes which happen as men grow older. Prostate diseases can be very worrying but it is important to know that BPE is not prostate cancer. BPE does not become prostate cancer, even if it is left untreated. However, both benign prostatic enlargement and prostate cancer may develop with age and coexist. You should consult your urologist to discuss any of your concerns.
What are BPH, BPE, and BPO? Benign prostatic hyperplasia (BPH) is a common benign condition which happens to some extent in all men. This condition is related to hormonal changes which happen as men grow older. In about half of these men, BPH may result in benign prostatic enlargement (BPE). In turn, this enlargement may obstruct the flow of urine, a condition which is called benign prostatic obstruction (BPO). BPO happens in about half of men with a benign prostatic enlargement. Your doctor may be referring to your condition by using either of the three terms, because these conditions are closely related.
You have been diagnosed with benign prostatic enlargement (BPE) and your doctor recommends drug treatment. This treatment is advised when the symptoms are bothersome and affect your quality of life. This section describes different drug treatments, which you should discuss with your doctor. Together you can decide which approach is best for you.
Factors which influence this decision include:
- Your symptoms
- The size of your prostate
- Your medical history
- Drugs available in your country
- Your personal preferences and values
There are several groups of drugs to treat the symptoms caused by BPE:
- Herbal drugs
- 5alpha-reductase inhibitors (5ARIs)
- Muscarinic receptor antagonists (MRAs)
- Phosphodiesterase 5 inhibitors (PDE5Is)
- A combination of drugs
Each group of drugs works in a different way and can have different results and side effects
Herbal drugs are made of plant extracts. Many types of roots, seeds, pollen, bark, or fruits can be used alone or in combination to make these drugs. The most widely used extracts in herbal drugs are taken from:
- Pumpkin seeds (Cucurbita pepo)
- South African star grass (Hypoxis rooperi)
- Bark of the African plum tree (Pygeum africanum)
- Rye pollen (Secale cereal)
- Berries of the American dwarf palm (Serenoa repens)
- Roots of the stinging nettle (Urtica dioica)
It is not entirely clear how these herbal drugs work to relieve symptoms caused by BPE. It is also not clear how efficient they are. The quality of herbal drugs can vary greatly. Because there are so many herbal drugs available, no specific recommendation about their use can be made. Inform your doctor during consultation if you take any herbal drugs to relieve your symptoms.
Side effects of herbal drugs are mild and many men do not experience any side effects at all. Gastro-intestinal discomfort (for instance bloating or constipation) is the most common complaint.
Alpha-blockers are a group of drugs which improve the symptoms and the flow of urine by relaxing the smooth muscles of the prostate. This is the most commonly recommended group of drugs for men with BPE. Currently, five main types of alpha-blockers are used. They all achieve similar results but differ in their side effects:
Usually the drugs are fully effective within a couple of weeks, but some men will notice an improvement within hours or days after starting treatment. Alphablockers do not reduce the size of the prostate or prevent it from growing. Some men will eventually need surgery to relieve their symptoms.
Side effects of alpha-blockers are mild and most men do not experience any side effects, even if they use them for a long time. Men who have side effects report loss of strength (asthenia), dizziness, and slightly lower blood pressure (hypotension).
Alpha-blockers may also cause retrograde ejaculation. This is an uncommon side effect and it will disappear when the treatment is stopped.
Alpha-blockers may affect the muscles in your eyes. This side-effect is not harmful but if you are scheduled to have cataract surgery you should inform your surgeon about the treatment with alpha-blockers.
5 alpha-reductase inhibitors
5alpha-reductase inhibitors (5ARIs) are a group of drugs which prevent the prostate from growing and may even shrink it. These drugs work better in prostates larger than 40 millilitres and are only prescribed when the prostate enlargement causes bothersome symptoms. 5ARIs will improve the symptoms 3 to 6 months after starting treatment. These drugs may reduce the risk of urinary retention and the need for surgery. 5ARIs take a long time to improve the symptoms, so they are only advised for treatment which lasts over a year.
There are 2 types of 5ARIs, and they achieve similar results:
The side effects of these drugs are mainly related to sexual function. They may include reduced sexual drive, erectile dysfunction, and problems with ejaculation. About 1-2% of men experience breast enlargement or nipple tenderness. Side effects are not very common and disappear when the treatment is stopped. There may be a relation between the use of 5ARIs and high-risk prostate cancer. This is a controversial topic and it is the subject of discussion.
5ARIs are generally recommended for men with moderate or severe symptoms because of the possible side effects.
These drugs are most often used in combination with other types of drugs. Possible combinations of drugs are discussed later in this section.
Muscarinic receptor antagonists
Muscarinic receptor antagonists (MRAs) are a group of drugs which reduce the abnormal contractions of the bladder. These drugs are usually prescribed for the treatment of overactive bladder symptoms. They can also help men with urgency symptoms caused by BPE. They are generally not prescribed if the bladder does not empty completely and there is much urine left in the bladder after urination.
There are several types of MRAs:
- Trospium chloride
Side effects of MRAs are usually mild. They may include dry mouth and eyes, constipation, difficulties urinating, symptoms of the common cold, blurred vision, and dizziness.
Phosphodiesterase 5 inhibitors
Phosphodiesterase 5 inhibitors (PDE5Is) are a group of drugs used for the treatment of erectile dysfunction. These drugs can also improve some symptoms caused by BPE. However, they are not officially registered as drugs for the treatment of BPE.
There are three types of PDE5Is:
Only tadalafil has been approved for the treatment of men with BPE. The cost is usually not covered by insurance companies or national health services.Men with erectile dysfunction as well as BPE may benefit from treatment with PDE5Is.
PDE5Is can cause side effects such as headache, back pain, dizziness, and indigestion. PDE5Is are contraindicated in combination with several drugs, including the alpha-blockers doxazosin or terazosin. They are also contraindicated in men who have specific heart problems. Men who have problems with their blood pressure or who have kidney failure should also not take PDE5Is. If you experience loss of vision when taking PDE5Is, you should go to your doctor.
Make sure to discuss any of your concerns about the side effects or contraindications of PDE5Is with your doctor.
Combinations of drugs
Your doctor can also advise a combination of drugs. The most common combinations are:
- Alpha-blockers with 5ARIs
- Alpha-blockers with MRAs
The aim of such treatment is to combine the benefits of both drugs. When used together, these drugs can be more effective but they may cause side effects more often. The side effects of each drug are described earlier in this section. Combination treatment is generally recommended for men with moderate or severe symptoms.
Alpha-blockers with 5ARIs
The combination of alpha-blockers with 5ARIs is recommended if:
- The prostate is larger than 40 millilitres
- PSA values are 1.5 ng/ml or higher
- Your symptoms are severe
- You have slow flow of urine
This combination of drugs is only advised for longterm treatment.
Alpha-blockers with MRAs
The combination of alpha-blockers and MRAs is recommended if:
- You have storage symptoms (See Symptoms and Diagnosis of BPE)
- Your symptoms have not improved when taking one drug
Benign prostatic enlargement (BPE) can affect the way you normally urinate. This happens because the enlarged prostate compresses the urethra at the outlet of the bladder (Fig. 1a and b). Sometimes the symptoms are mild. For example you may need to urinate more often or find it more difficult to empty your bladder completely. These mild symptoms are a normal part of the ageing process – just like decline in mobility, memory, or flexibility. It is possible that your doctor will not recommend treatment for mild symptoms.
Sometimes the symptoms are very bothersome and can have a negative effect on your quality of life. In this case you may benefit from treatment
The symptoms which are often called lower urinary tract symptoms (LUTS) may be caused by BPE and may be due to other conditions which affect the urinary system.
Types of symptoms
In men with BPE, the symptoms can affect urination in different ways:
- The way you hold the urine in the bladder (storage)
- The way you urinate (voiding)
- How you feel after you urinate (post-micturition)
Storage symptoms include:
- The need to urinate more often than usual
- The need to wake up at night to urinate
- The sudden need to urinate and having trouble postponing it
- Any involuntary loss of urine
Voiding symptoms include:
- A weak stream of urine
- Splitting or spraying of the urine stream
- The flow of urine starts and stops
- Straining when urinating
- It takes a while before the urinary flow starts
- It takes longer to finish urinating
- In rare cases acute or chronic urinary retention
Post-micturition symptoms include:
- The feeling that the bladder is not completely empty
- Involuntary loss or dribbling of urine into your underwear shortly after leaving the toilet
The doctor and nurses do a series of tests to understand what causes your symptoms. This is called a diagnosis.
The symptoms listed in the previous section can point to many diseases and not only BPE. This is why you may need to take several tests before the doctor can make a diagnosis.
First, the doctor or nurse will take your medical history and do a physical examination. Then they may do urine and blood tests, take images of your bladder and prostate, and perform other tests if needed.
This section offers general information about diagnosis and situations can vary in different countries.
The doctor will take a detailed medical history and ask questions about your symptoms. You can help your doctor by preparing for the consultation:
- Make a list of any previous surgeries
- Make a list of the medication you are taking
- Mention other diseases you suffer from
- Describe your lifestyle (exercising, smoking, alcohol, and diet)
- Describe your current symptoms
- Note how long you have had the symptoms for
The doctor may also ask you to fill out a questionnaire to understand your symptoms, how often they happen, and how much they affect your quality of life. There are several questionnaires available including IPSS, ICIQ Male LUTS, the Danish Prostate Symptom Score (DAN-PSS). The most-used questionnaire is the International Prostatic Symptom Score (IPSS). It consists of seven questions about your symptoms which can be scored between 0 and 5, from mild to severe.
- LUTS – Lower urinary tract symptoms
- Micturition – Urination
- Nocturia – The need to wake up at night to urinate
- Post void residual urine (PVR) – The amount of urine left in the bladder after urination
- Urinary incontinence – Involuntary loss of urine
- Urgency – The sudden need to urinate which is difficult to postpone
Your doctor or nurse will do a general physical examination.>
They will be looking for:
- A distended bladder (your bladder may stretch if it does not empty completely)
- Skin damage on the penis and scrotum (a sign of urinary incontinence)
- Discharge from the urethra (a sign of infection)
- Abnormalities in the penis, scrotum, and testicles
In addition, your doctor will do a rectal examination with a finger to feel the size, shape, and consistency of the prostate (Fig. 2). This test is known as digital rectal examination (DRE). Urine test
You will need to give some of your urine for testing. The test will show if you have a urinary tract infection and if there are traces of blood in the urine.
As part of making the diagnosis your doctor may do a blood test to check your kidney function. The doctor may also recommend to check if your blood has higher levels of prostate-specific antigen (PSA). PSA is a protein produced by the prostate and it may increase in men with a benign prostatic enlargement, prostatic inflammation, or prostate cancer. The doctor will explain the possible consequences of this test before making this recommendation.
Your doctor may ask you to keep a bladder diary.Here you will note down how much you drink, how often you urinate, and how much urine you produce by measuring the volume of urine at home with the help of a measuring jug. The bladder diary is important because it helps your doctor to understand your symptoms better
You may use a stopwatch to record the time it took you to urinate. Note down the amount of urine (in millilitres) and the time (in seconds)
This is a simple test which electronically records the flow of urine. It is easily done in privacy at the hospital or clinic. You will urinate in a container, called a uroflowmeter (Fig. 4). This test helps your doctor to check if the enlarged prostate causes a blockage in the lower urinary tract. Fig
- Normal urine flow is above 15 millilitres per second.
- If your flow of urine is 10 millilitres per second or less and you experience symptoms, you should see your urologist.
Imaging of the urinary tract
You may get an ultrasonography (also known as ultrasound), which uses high-frequency sounds to create an image of your bladder and your prostate.
The doctor or nurse will scan your bladder using ultrasound to check how much urine is left in the bladder after urinating. This information helps to see if your symptoms are caused by chronic urinary retention, which can occur in men with BPE.
An ultrasound may also be used to measure prostate volume. This may help to select the best treatment option for you.
A urodynamic test is done to get more information about your urination cycle and how your bladder muscles work. During the test, your doctor inserts catheters in your urethra and rectum to measure the pressure in your bladder and abdomen.
The bladder is slowly filled with sterile fluid through the catheter in the urethra. In this way, the filling of the bladder with urine is simulated. When the bladder is full, you will urinate into a uroflowmeter. The test results are shown on a screen which is connected to the catheters. Sometimes the test has to be repeated to get accurate results but the catheters will already be in place for the second test.
Your doctor may decide to give you this test if:
- You have a neurological dysfunction
- You have had pelvic or prostate surgery
- You have much urine left in the bladder after urination
- BPE is uncommon in your age group
- The urologist needs more information to understand the cause of your symptoms
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