Treatment of Benign Prostatic Hyperplasia (BPH) -medication
Overview by Mr Marc Laniado
Consultant Urological Surgeon
Frimley Park NHS Foundation Trust
Royal Berkshire NHS Foundation Trust
Before medication, try the following life style changes to see if they help:
- avoid alcohol, fizzy drinks, and caffeine, which is found in coffee and tea. Substitute decaffeinated drinks where possible
- gradually train your bladder by holding on and delaying for more extended periods over several weeks
- allow enough time at the toilet when you pass urine so that your bladder can empty. After you think you have finished, wait a moment and try to go again
- move your bowels regularly and avoid constipation
- drink enough to keep your urine a light straw colour, but not completely transparent or dark – typically, this means drinking 1½ to 2 litres daily in the UK
- keep your weight down so that your body mass index (BMI) is less than 29
- do not lift heavy items
- stop or do not begin smoking
- avoid cold and allergy medicines with antihistamines or decongestants, as these worsen urinary symptoms
- Do pelvic floor exercises for men
If you get up at night several times to pass urine, the following actions can help:
- in the 4 hours before you to bed at night, elevate your legs and do not drink
- exercise, e.g. walking, cycling or running, between 3 to 4 hours before going to bed
- adopt habits to sleep better, such as going to bed and getting up at similar times, avoiding alcohol and heavy meals one to two hours before bedtime, and taking short but not long naps in the afternoon
If you leak urine as you walk away from the toilet, try the following:
- after passing urine, wait for a few seconds to allow the bladder to empty
- place the fingertips of the left hand 3 fingerbreadths behind the scrotum and press gently in the midline
- draw the fingers forwards towards the base of the penis under the scrotum to push urine into the penile urethra
- shake or squeeze the penis in the usual way to empty the penile urethra
- repeat the technique twice to ensure that the urethra is empty before leaving the toilet
This technique can be practised at home. When in public toilets it can be done discreetly, with a hand inside a trouser pocket.
If these steps are not enough, medications taken singly or in combination can help.
The most frequently used drug is tamsulosin. Urinary symptoms improve two or three days in 70% of men who take, it and the benefit can last several years. If there is no benefit by two weeks, then alpha blockers will not be helpful in the long-term. About 1 in 7 men may feel dizzy because the blood pressure drops, 1 in 12 men feel tired and do not ejaculate semen when they have an orgasm. Other side-effects include headaches and nasal congestion. Alfuzosin is an alternative to tamsulosin, and more men ejaculate as usual with alfuzosin than tamsulosin.
5-alpha reductase inhibitors (5ARI):
The commonest used is finasteride and then dutasteride. Symptoms improve after 6 to 12 months, so patience is needed, but fewer men need surgery if 5ARI are taken for many years. 5ARI are more effective in men with large than average-sized prostates. The main side effects are reduced libido, reduced semen volume, weaker erections in 5 to 15% of men who take the drugs. Some men also get depression, and there is a slightly higher risk of getting diabetes. Men who want to have children should not take the medications as it harms sperm.
These include oxybutynin, solifenacin and trospium. These are best if you have symptoms of the overactive bladder, e.g. if you need to pass urine often and need to rush to the toilet or leak urine before you get there. It is best not to take these if your bladder does not empty fully, as they can make that worse. The side-effects vary a little by the drug but include a dry mouth, blurred vision, a fast heart rate, thinking less clearly, and constipation.
The main drug used is tadalafil. It can take one to four weeks before you notice a benefit, and the benefit is slightly less than with alpha blockers.
You can combine the drugs above in some circumstances.
Alpha blockers and 5ARI:
taking both drugs has more benefit than one alone, so if alpha blockers are not enough and the prostate is large, taking both may help. Adding a 5ARI does not help unless the prostate is big.
Alpha blockers and anticholinergic agents:
If you have to rush frequently and urgently to the toilet despite taking an alpha blocker, adding an anticholinergic can help. It is essential to ensure the bladder empties well when taking an anticholinergic. If symptoms are still poor with an anticholinergic alone, adding an alpha blocker can help
Alpha blocker and phosphodiesterase inhibitors:
If you have urinary symptoms and problems with erections, the combination would be better. As both drugs can lower the blood pressure and cause light-headedness, at least four hours should be left between taking the individual drugs.
There is a lack of good quality evidence on how well and professional bodies do not recommend these. However, many men use saw palmetto, beta-sitosterol, rye pollen extracts, and Pygeum Africanum.
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