By Annette M. Boyle

GAINESVILLE, FL — Treatment of benign prostatic hyperplasia (BPH), the fourth most common diagnosis among VA patients over 50 years old, has changed radically in the last 15 years, with better management and medications making surgery a less-attractive option in most cases.

Even when surgery is deemed necessary, lasers are increasingly likely to be used, instead of the traditional surgical procedure at the VA, partly because recent studies have shown they significantly decrease costs without sacrificing effectiveness.

During the late 1990s, perhaps “75% of men with BPH would have been managed surgically. Today 75% are managed medically,” according to Benjamin Canales, MD, MPH, Malcom Randall VA Medical Center, Gainesville, FL.

The VA now recommends using “watchful waiting” for men who have mild BPH symptoms, as indicated by an American Urology Association severity index (AUA-SI) of seven or less and for those who tolerate moderate symptoms well. Once symptoms advance, treatment options multiply, but so does the controversy surrounding them.¹

The primary medications used to treat BPH are 5-alpha reductase inhibitors (5-aRIs) such as finasteride and alpha-1-adrenergic receptor (a-1-AR) antagonists such as terazosin, alone or in combination. The VA Cooperative Studies Benign Prostatic Hyperplasia Study Group compared the relative effectiveness of the two classes of drugs in a study of 1,229 men with symptomatic BPH. Based on the results of that study, the VA’s Evidence Synthesis Pilot Program-Benign Prostatic Hyperplasia recommended prescribing alpha-blockers alone for the first year of treatment in most men^{. 2}

The authors concluded that, “in the first year of treatment, alpha-blockers are more effective than finasteride in improving symptoms. Combination therapy and an alpha-blocker alone have similar effects on quality of life in the first year and a half of treatment.”

In practice, Canales finds whether to use one or more drugs comes down to patient willingness. “It’s hard enough to convince a man to take one pill; starting with two pills typically doesn’t work.”

Beginning treatment with alpha-blockers also makes more sense, as they have far fewer side effects, even though combination therapy has been shown to be highly effective, noted Canales. “Hypotension is the most notable side effect. If a patient still has symptoms after taking an alpha-blocker, we would add a 5-aRI.”

Normal prostate (left) and benign prostatic hyperplasia (BPH). A normal prostate does not block the flow of urine from the bladder. An enlarged prostate presses on the bladder and urethra and blocks the flow of urine. Source: National Cancer Institute.

For men who have BPH with a significantly enlarged prostate or high PSA at baseline evaluation, the comparative review’s recommendation is a little less clear. Report authors note that “combination therapy can prevent about two episodes of clinical progression per 100 men per year over four years of treatment.” On the downside, however, “most men who take combination therapy will have no additional benefit, and about four additional patients per 100 will become impotent who would not have taking an alpha-blocker alone.”

“It would be very unusual to start with a combination,” Canales told U.S. Medicine. “And yet, we know combination therapy works. The Medical Therapy of Prostatic Symptoms (MTOPS) trial in 2003 proved that, in this instance, one plus one equals five.” ³

MTOPS showed that combination therapy halved symptom progression and reduced the incidence of invasive surgery by 80%.

 “If a patient has a very large prostate and urinary retention, he might take both drugs and stay on them for life. But 5-aRIs can cause gynecomastia and have sexual side effects. Most men will not continue to take a pill that reduces libido,” Canales added.