Historically, BPH management was relatively simple, relying heavily on alpha-blockers and surgical interventions like transurethral resection of the prostate (TURP). If symptoms were unresponsive to medication, surgery was the next logical step. However, with advancements in medical treatments and technologies, the management of BPH has become more nuanced.
Today, there is a broader spectrum of treatments, including newer classes of medications and a variety of surgical and minimally invasive procedures. This expanded range of options can be overwhelming, akin to navigating a cluttered array of choices. Despite these advancements, the core principles of BPH management remain consistent.
Around 33% of men >50-years seek treatment for BPH symptoms, which typically include a reduced urinary stream, hesitancy, post-micturition dribbling, increased nighttime urination, and urgency. The initial evaluation involves a comprehensive history, physical examination, and a prostate-specific antigen (PSA) test to exclude prostate cancer.
Alpha-blockers remain the cornerstone of BPH treatment. These medications work by relaxing the muscles in the bladder neck and prostate, improving urine flow. Traditional alpha-blockers have largely been replaced by more selective agents such as tamsulosin and silodosin, which target alpha-1 receptors in the prostate and bladder neck with fewer side effects, notably postural hypotension.
The advent of these highly selective alpha-blockers has marked a significant improvement in BPH management. These drugs reduce symptoms more effectively with fewer side effects, making them suitable for patients, particularly older individuals, who may be prone to complications from less selective alpha-blockers. Silodosin, for instance, is particularly beneficial for managing acute urinary retention and minimising complications after surgery.
However, selective alpha-blockers can affect ejaculatory function, leading to difficulties with ejaculation due to excessive relaxation of smooth muscles. While this side effect is manageable, it remains a significant consideration when choosing therapy.
In some cases, combination therapy is employed. This approach might involve an alpha-blocker and a 5-alpha reductase inhibitor like finasteride or dutasteride. These inhibitors reduce prostate size but require several months to show effects, making them suitable as adjunctive therapy rather than first-line treatment. Combination therapy may also include antimuscarinic agents to address overactive bladder symptoms, though this combination is not yet widely used due to potential interactions.
Surgical options for BPH include TURP, which remains the gold standard due to its effectiveness in mechanically widening the urethra. Alternative surgical techniques like laser therapies are available for large prostates and offer less risk of complications compared to traditional methods. Other experimental methods, such as cryotherapy and prostate artery embolisation, are less commonly used.
The introduction of new treatments and technologies has made BPH management more complex, necessitating clear communication about potential side effects and treatment expectations. Patients often feel frustrated when side effects are not adequately discussed beforehand. Effective patient education about the potential impact on sexual function, including reduced ejaculate volume, is crucial for maintaining patient satisfaction and addressing concerns proactively.
In summary, while the treatment options for BPH have expanded, the fundamental approach to managing the condition remains consistent. Alpha-blockers continue to be the primary therapy, with newer, more selective agents offering advantages in specific contexts. The choice of treatment should balance effectiveness with potential side effects, considering individual patient needs and circumstances. Clear communication with patients about their treatment options and potential side effects is essential for ensuring a satisfactory treatment experience and achieving optimal outcomes.
To watch a replay of the webinar, click here.
