Prostate

The management of BPH depends to some extent on the severity of the symptoms. The classic symptoms include increased frequency of urination, urinary hesitancy, incomplete emptying of the bladder, straining to void, nighttime voiding, and poor stream. Surgery has been the mainstay of treatment for BPH; however, since the mid-1980s, pharmacological and minimally invasive options have become available. Certain situations, however, are generally considered absolute indications for surgery. These include kidney failure, complete inability to void, chronic urinary tract infections, or bladder stones. Patients without these indications should consider lifestyle or pharmacological options. Many patients may be satisfied after appropriate reassurance and minor lifestyle changes, such as decreased fluid intake in the evening. Others find the symptoms too disruptive and should consider pharmacological therapy or surgery.

Two classes of drugs are commonly used for men with mild to moderate symptoms. The first are alpha-adrenergic blocking agents that act on receptors in prostatic smooth muscle to decrease resistance to urinary outflow. This class includes terazosin, doxazosin, and tamsulosin. Several well-controlled studies have demonstrated the efficacy of such drugs in improving symptoms (Lepor). The second class of drugs are androgen deprivation agents, which include finasteride. This drug inhibits the conversion of testosterone to dihydrotestosterone, thus blocking the action of testosterone on the prostate. This has been reported to reduce prostate size. A study in the late 1990s, however, has demonstrated no improvement in symptoms in men with prostates that were not enlarged (Lepor).

Patients with moderate to severe symptoms who fail or cannot tolerate medical therapy should consider surgery. Surgical removal of the prostate for BPH in most cases is performed by a transurethral resection of the prostate, in which the obstructing portion of the prostate is removed with a urethral telescope and electrical "knife." This procedure can also be performed using a laser, with similar effectiveness. In approximately 10 percent of patients who require surgery for BPH, the prostate is too large to be removed through a scope, and in these cases open surgery is used to remove the obstructing portion of the gland. Whether preformed through a scope or open, surgery success in terms of patient satisfaction is approximately 90 percent (Mebust). It is not associated with incontinence and should not affect erections, though frequently the ejaculate may go back into the bladder because the bladder can no longer close during ejaculation (Mebust).