This analysis compares the effectiveness, safety, and cost of medicines used to treat urination problems due to prostate enlargement, a condition also known as benign prostatic hyperplasia (or hypertrophy), or BPH. It is based on an analysis of the scientific evidence on drugs to treat BPH, including studies from the 1960s through late 2008.
Prostate enlargement, or BPH, affects millions of men in the U.S., mostly those ages 50 and older. While it can be a serious condition in some cases, it’s important to note that it is not prostate cancer, and that many men who have been diagnosed with BPH have no symptoms at all or symptoms that are minor and not very bothersome.
It’s also important to emphasize that BPH does not raise your risk of prostate cancer. The prostate becomes larger in all men as they age, and how slowly or rapidly that occurs does not appear to be linked to one’s risk of prostate cancer. That said, BPH symptoms (see the list of symptoms below) can be similar to the symptoms of prostate cancer. So it’s important to be checked by a physician if you notice changes in your typical urination patterns or have other BPH symptoms. It’s also possible to have BPH and prostate cancer at the same time, underscoring the need to get checked.
Almost all men—once they reach a certain age—will develop BPH. The statistics are not precise, but by age 55 or so, about half of all men have an enlarged prostate. By age 65, the figure is up to nearly 75 percent, and by age 80, nine in 10 men have BPH. But only about half of men will have symptoms that warrant treatment.
BPH symptoms, which usually involve problems with urinating, aren’t hard to detect. And why they occur is pretty well understood. The normal function of the prostate is to produce semen, the fluid that carries sperm during ejaculation. The prostate surrounds the urethra, the tube that carries urine from the bladder and out of the body. When the prostate becomes enlarged, it pinches the urethra. This partly—and sometimes completely—restricts the flow of urine or causes difficulty urinating.
An enlarged prostate also triggers changes in your bladder. As the urethra becomes narrow, the bladder has to work harder, which can cause its walls to become thick. This can make your bladder contract when it contains only a small amount of urine. Your bladder can also become distended and lose its muscular tone. This combination of factors results in incomplete bladder emptying, which can make you feel as though you have to urinate more often and lead to other problems.
The symptoms of BPH include:
■ slowed or delayed start to urinating
■ needing to urinate more often
■ needing to urinate two or more times during the night
■ weak flow of urine
■ dribbling of urine after finishing
■ straining to urinate
■ strong and sudden urge to urinate
■ feeling that the bladder is not completely emptied after urinating
■ sudden inability to urinate
■ incontinence (urine leakage)
These symptoms can have a negative impact on your quality of life depending on their severity. Men who get up three or four times at night to urinate, for example, can be tired the following day. BPH can also inhibit some men from engaging in routine activities like sports or going to the movies because of anxiety about the need to use the restroom.
BPH symptoms are usually mild for most men. But when they become bothersome or even severe it’s important to seek help because, if left untreated, prostate enlargement can lead to such complications as urinary-tract infections and kidney damage. Also, contact your doctor immediately if you have fever or chills, pain in your back, side or abdomen, cloudy or bloody urine, or pain when urinating. These symptoms could be a sign of complications that require medical attention.
What causes the prostate to enlarge as men become older and why it occurs in some men more than others is not well understood. A hormone related to testosterone, called dihyroxytestosterone, or DHT, is thought to play an important role. Some men prone to developing a more severely enlarged prostate may have higher than average DHT levels in their blood, or their prostates may become more sensitized to its effects after age 60.
Family history also plays a role. Men whose fathers and/or grandfathers had BPH are more likely to develop it. Some studies have suggested that black and Hispanic men may be more prone to urination problems related to BPH than white men, but recent studies have found little, if any, difference in rates of the condition by race.
There are several treatment strategies that can help provide relief. Lifestyle changes (which are discussed in the Treatment Options section below) can often be enough, but if they fail to improve symptoms, then medication might be necessary.
This analysis focuses on the two classes of drugs commonly used to treat prostate enlargement: alpha-blockers and 5-alpha-reductase inhibitors. Table 1 lists the seven alpha-blockers and two alpha-reductase inhibitors used to treat BPH. (The differences between the two drug classes are discussed later.)