Choosing the Right Treatment for Enlarged Prostate

Medications to treat enlarged prostate can improve urinary symptoms, but also cause sexual side effects. Surgical solutions can cause sexual side effects, too. No wonder so many men delay seeking treatment!

“There is significant fear in men,” said Alex Shteynshlyuger, MD, director of urology at New York Urology Specialists. “I have patients who drive for years with a pee bottle in the car.”

Unfortunately, doing nothing isn’t a good option. The prostate, a gland that surrounds the urethra, gets gradually bigger throughout the lifespan. As it enlarges, it compresses the urethra, making it difficult to empty your bladder. If urine is retained in the bladder, you may get a urinary tract or kidney infection, both of which can be serious and progress to sepsis, a potentially life-threatening complication.

Understanding the treatments available for benign prostate hyperplasia (BPH, aka “enlarged prostate”) will help you select the treatment that’s right for you and your life.

Medication for BPH

Doctors use 3 classes of drugs to treat BPH: alpha-1 adrenergic antagonists (“alpha blockers”), 5-alpha reductase inhibitors and phosphodiesterase-5 inhibitors.

Alpha Blockers

Flomax, Hytrin and Rapaflo (alpha blockers) are the medications most often used to treat BPH, said Ralph Esposito, ND, LAc, a naturopathic physician and acupuncturist who specializes in men’s health and urology at The Center of Excellence in Generative Medicine in Bridgeport, CT. Commonly prescribed alpha blockers include Flomax (tamsulosin), Hytrin (terazosin) and Rapaflo (silodosin).

These medications don’t change the size of the prostate; they relax the muscles around the prostate and bladder, making it easier to pee. They “are very effective, especially when the condition starts,” Dr. Shteynshlyuger said. “They can decrease frequent urination and allow men to sleep through the night.” Side effects, Dr. Shteynshlyuger said, are “mostly inconvenient” and include dizziness and what’s called retrograde ejaculation. (Instead of ejaculating externally, semen is redirected to the bladder.)

“Not ejaculating [externally] is not a dangerous problem, but can affect sexual interaction,” Dr. Shteynshlyuger said. Of course this would affect fertility, but not consistently enough to depend upon as a birth control.

Flomax was the first treatment James Huber, a retired human services director in Woodbury, MN, tried when he sought help for BPH. “I took that for the better part of a year, but still had frequent urination.” After talking to his friends and conducting some internet research, he told his doctor he’d like to try Avodart (dutasteride), a 5-alpha reductase inhibitor.

5-Alpha Reductase Inhibitors

Avodart and Proscar (5-alpha reductase inhibitors) shrink the prostate. They do so by reducing levels of a testosterone metabolite in the body. Because these drugs affect male hormones, common side effects include decreased libido and sexual function. Avodart and Proscar (finasteride) are 2 commonly prescribed 5-alpha reductase inhibitors.

A desire to avoid hormone-related side effects caused Joe Bunton to reject medication to treat his BPH. “These drugs can shrink up the prostate,” said Bunton, a Colorado-based sports car driver, pilot and retired engineer. “Some of my golfer geezer buddies who have been taking that stuff, they grow boobs, they get their shoulders slumped and their muscle mass goes away.”

Indeed, side effects of 5-alpha reductase inhibitors include breast enlargement, ejaculatory dysfunction and difficulty getting or maintaining an erection. Because these drugs can affect sexual function, they are not often prescribed for men who have healthy sex lives. “Guys with good erections, we try not to give it to them,” Dr. Shteynshlyuger said. “However, if men already have a problem with erection, these medications can be a good option for BPH, because they will need treatment with Viagra or Cialis for erectile dysfunction (ED) anyway.”

5-alpha reductase inhibitors can be used in conjunction with alpha blockers. That’s what Huber tried – Flomax plus Avodart. “That worked really well,” he said. “But the side effect was that I could get pretty dizzy. I took my meds before I went to bed, so if I had to get up, I had to be careful because I would be dizzy.”

Because these medications gradually shrink the prostate, it can take 3 to 6 months to see the full benefit of treatment, Dr. Shteynshlyuger said.

Phosphodiesterase-5 Inhibitors

Cialis and Viagra (phosphodiesterase-5 inhibitors) are most commonly used to treat ED, but can also be used to treat BPH. In fact, using Cialis (tadalafil) and Viagra (sildenafil) in conjunction with another type of BPH med may be more effective than taking either one alone.

A 2016 study of 103 men that compared treatment with Rapaflo (silodosin, an alpha blocker) alone to treatment with Rapaflo and Cialis found that the combination therapy resulted in significantly greater improvements in urinary symptoms. Urinary flow and quality of life were both improved with combination therapy; no significant differences in side effects were observed.

Common side effects of phosphodiesterase-5 inhibitors include headaches, flushing of the face or upper body, back and muscle pain, indigestion, vision problems and a stuffy nose.

Currently, Cialis is the only phosphodiesterase-5 inhibitor that is FDA approved to treat BPH. However, physicians can prescribe phosphodiesterase-5 inhibitors that have been FDA approved for other indications (such as ED) to treat BPH.

Surgical Treatment of BPH

When the prostate has enlarged to the point that treatment with medication isn’t sufficient to control symptoms, surgical treatment is recommended. Surgical options include:

TURP (transurethral prostate resection), the so-called “roto-rooter” procedure that removes tissue from the prostate. In many places, lasers are now used to perform TURPs. Side effects may include retrograde ejaculation, impotence and urinary incontinence.

Rezum, a minimally invasive procedure that uses steam to remove excess prostate tissue. James Huber selected this option when medication could no longer control his symptoms. “It took a couple of weeks after the procedure to feel normal. At first, you’re passing a lot of blood, and I had to withdraw from my Avodart and Flomax gradually. But there are no [lasting] side effects,” Huber said. “I can now go through an entire movie at the theater without having to get up.” Rezum was FDA approved in 2015.

Side effects of Rezum typically resolve within a few weeks and may include blood in the semen and urine, painful urination and temporary need for a catheter to empty the bladder.

PAE (Prostatic artery embolization), a relatively new procedure that’s only available at a few medical centers throughout the country. During PAE, physicians introduce microscopic beads into the bloodstream via an incision in the groin; these beads block the blood supply to the prostate and cause it to shrink.

Joe Bunton underwent this procedure in the spring of 2016. “It’s made a huge difference to me,” he said. “I’m not peeing like a horse, but it sure feels like it.” He’s had no adverse sexual side effects. In fact, Bunton said, “if anything, it’s a positive effect. I feel more confident and want to have sex more often.” Side effects of PAE include mild pain post-procedure.