muscles surrounding the urethra. However, in men who have a bladder neck that does not close properly, such as those men who are on alpha blockers, there is a propensity for the semen to travel in a retrograde fashion back into the bladder rather than out through the urethra. This is not a dangerous situation, but it does result in the presence of a dry orgasm, which is alarming for some men.
5–alpha reductase inhibitors (Table 2) are a fairly new drug class available to physicians. They were first introduced to the US in 1996. There are two drugs that are currently available in the United States: finasteride (Proscar) and dutasteride (Avodart). These work in an entirely different fashion to alpha-blockers.They actually shrink the prostate by blocking the production of 5–alpha reductase. Remember that 5–alpha reductase is that enzyme that degrades testosterone to DHT, the latter being the primary hormone that causes prostate growth. These agents can take between three to six months to effect any significant reduction in prostate size and usually, at best, men have a 30 to 50% reduction in their prostate size. It is also important to understand that 5–alpha reductase inhibitors will reduce the PSA level by approximately 50%, and therefore, it is critical that a man have his PSA level checked before starting one of these drugs. 5–alpha reductase inhibitors are also used for male pattern baldness. In fact, the first commercially available male baldness drug, Propecia, is low-dose finasteride.
| Table 2 • Medications for LUTS |
| Alpha-Blocking Agents |
| Doxazosin (Cardura) |
| Terazosin (Hytrin) |
| Tamsulosin (Flomax) |
| Alfuzosin (Uroxatral) |
| 5–Alpha Reductase Inhibitors |
| Finasteride (Proscar) |
| Dutasteride (Avodart) |
Most urologists tend to reserve the use of 5–alpha reductase inhibitors as a first-line treatment for men with very large prostates. For men with small to medium prostates, alpha-blockers are typically first-line. However, there is recent evidence that the combination of both may, in fact, be even more effective than the single agent alone.
There is great interest in the concept that 5–alpha reductase inhibitors might prevent prostate cancer. There is a single trial which was conducted, known as the Prostate Cancer Prevention Trial (PCPT). This was published a few years ago and demonstrated that the regular use of finasteride reduced the incidence of prostate cancer, but when prostate cancer was present, the Gleason grade (the assessment of the aggressiveness of the tumor) was increased. There remains confusion regarding this data and at this point in time most authorities suggest that 5–alpha reductase inhibitors should not be used as a prostate cancer prevention strategy.
| Table 3 • Surgical Options for BPH |
| Open |
| Suprapubic (simple) prostatectomy |
| Transurethral |
| Transurethral resection of the prostate (TURP) |
| Transurethral incision of the prostate (TUIP) |
| Minimally Invasive |
| Laser prostatectomy |
| Laser vaporization (TUVAP) |
| Transurethral microwave therapy (TUMT) |
| Transurethral needle aspiration (TUNA) |
The side effects of 5–alpha reductase inhibitors are not very common. Approximately 5% of men will complain of loss of libido, and approximately 1% of men will have some problems with erectile function. It is not uncommon for men to note some change in the volume of ejaculate. While beyond the scope of this book, there is a lot of interest in the use of herbal supplements (phytotherapy) for the treatment of benign prostate enlargement, and there are some, in particular saw palmetto, which have been shown in controlled trials to result in some improvement in urinary symptoms in men with BPH/LUTS.
IV. Surgical Treatment of BPH/LUTS
When medications are no longer effective in reducing the symptoms associated with BPH, most men are faced with the decision regarding surgery. Surgery is broken down into three categories (Table 3): 1) open surgery (where an incision is made in the abdomen), 2) transurethral surgery (where a telescopic device is passed through the urethra) and 3) minimally invasive procedures (usually performed in a doctor’s office or as an out-patient).
Historically, prostatectomy was performed through an abdominal incision, either through the capsule of the prostate (known as a simple retropubic prostatectomy) or through the bladder (known as transvesical prostatectomy). In modern urology, these procedures are reserved for patients who have very large prostate glands that are believed not to be amenable to trans-urethral procedures. Another situation in which the surgeon may opt for an open prostatectomy is if a patient also has bladder stones at the same time. Then the open procedure will enable the urologist to take care of the prostate enlargement as well as the bladder stones at the same time.
When the prostatectomy is effective, irrespective of how it is performed, virtually every man will have retrograde ejaculation. In fact, surgeons previously used this as an assessment of the effectiveness of their surgeries. Open surgery is associated with more bleeding than transurethral surgery usually, and as with any open operation, it is associated also with a low incidence of wound infections, blood clots (deep venous thrombosis) in the legs or lungs (pulmonary embolus) and pulmonary embolism. The incidence of erectile dysfunction occurring after prostatectomy for BPH is low.
The gold standard of treatment from the 1970s to the 1990s for BPH is known as TURP (transurethral resection of the prostate). Most patients who have had this procedure will tell you they have had Roto-Rooter procedures. With the patient under anesthesia and in stirrups, an instrument (known as a resectoscope) is passed with a video camera into the urethra and through the prostate, and then a cautery loop is used to scoop out the prostate from inside out. TURP surgery is done far less commonly today than it was 20 years ago. When I was in residency in the early 90s, one of the most common procedures performed on a daily basis in the operating room by urologists was the TURP. The decrease in use of this procedure has been due to improvement in medications for BPH as well as the introduction of minimally invasive technologies. It is a highly effective treatment for large prostate glands. In the hands of a well-trained surgeon, it is also a very safe procedure. A patient are required to spend a day or two in hospital afterward, will have a catheter in and will generally have blood in the urine for a couple of days, sometimes requiring continuous bladder water irrigation to make sure that no clots are formed. The procedure results in a dramatic improvement in urinary symptoms in men who have large prostate glands. It is not a good option for men who have small prostate glands but significant lower urinary tract symptoms.
Bleeding is not an uncommon problem with the TURP, but transfusion rates are generally less than 5%. Urinary infections occur in approximately the same percentage of people. There is an uncommon syndrome known as the TUR syndrome, whereby the fluid that is used to irrigate the bladder and prostate during the procedure gets absorbed into the blood stream and can result in significant problems with the chemicals (electrolytes) in the blood. The longer the procedure takes to finish and the deeper the prostate resection is, the more likely this is to happen. As you will read a number of times in this book, experience is a key factor in avoiding this complication.
A more modern form of TURP is known as transurethral vaporization of the prostate (TUVAP). Rather than a cautery loop, a specially
