Should I Use Medication or Watchful Waiting to Treat Benign Prostatic Hyperplasia (BPH)?

Introduction

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision

If your benign prostatic hyperplasia (BPH) is causing lower urinary tract symptoms, options include watchful waiting, medicine, and surgery. Generally, watchful waiting or medicines are considered first, and then surgery. This Decision Point focuses on deciding between watchful waiting and medicines.

Consider the following when making your decision:

If you have acute urinary retention (AUR, a blockage of the urethra that makes urination impossible) that comes back, urinary tract infections that happen again, kidney problems, bladder stones or bladder infections, or blood in your urine, watchful waiting or medicine is usually not an option. Talk to your doctor about surgery.
The American Urological Association (AUA) symptom index is used to help men determine the severity of their urinary symptoms and can also be used to measure the effectiveness of treatment. But the most important factor in deciding whether to get treatment is not your AUA rating, but how much the symptoms bother you and affect your quality of life.
Your BPH symptoms may come and go, stabilize, or get better over time. About 4 out of 10 men improve without treatment.¹
You may find the side effects of medicine more bothersome than your BPH symptoms.
Medicines may decrease the risk for acute urinary retention and future surgery.²

Medical Information

What is benign prostatic hyperplasia?

Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate gland that occurs in almost all men as they age. The enlargement is usually harmless, but it often results in problems urinating. About half of all men older than 75 have some symptoms.³

What are the risks of BPH?

BPH can be inconvenient and may affect your quality of life, but it is usually not a serious problem.

In a small number of cases, BPH may cause bladder outlet obstruction (BOO), making it impossible or extremely difficult to urinate. This may result in backed-up urine (urinary retention), leading to bladder infections or stones or kidney damage.

BPH may also irritate the bladder muscles as they enlarge to compensate for the increased force needed to empty the bladder.

BPH does not cause prostate cancer and does not affect a man's ability to father children. And it doesn't usually result in erection problems. But there is some association between severe symptoms of BPH and an increased risk of erection problems.

If you need more information, see the topic Benign Prostatic Hyperplasia (BPH).

Your Information

Your choices are:

Try watchful waiting. Manage your BPH through fluid intake and bathroom techniques, and see your doctor regularly to monitor your condition.
Use herbal therapy to relieve your symptoms.
Use prescription medicine to relieve your symptoms. Options include:
- Alpha-blockers, such as alfuzosin (Uroxatral), doxazosin (Cardura), tamsulosin (Flomax), and terazosin (Hytrin), which relax muscle tissue.
- 5-alpha reductase inhibitors, such as dutasteride (Avodart) or finasteride (Proscar), which shrink the prostate.

The decision about whether to use medicines for BPH takes into account your personal feelings and the medical facts.

The American Urological Association (AUA) symptom index is used to help men determine the severity of their urinary symptoms and can also be used to measure the effectiveness of treatment. But the most important factor in deciding whether to get treatment is not your AUA rating, but how much the symptoms bother you and affect your quality of life.

**Deciding about using a medicine to treat BPH**
Reasons to use medicine	Reasons not to use a medicine but to practice watchful waiting
You have moderate to severe symptoms that bother you. You have tried to manage your BPH through watchful waiting, but your symptoms still bother you. You have a large prostate, and your doctor feels that you may be at risk for urinary retention. You may reduce your risk of acute urinary retention and future surgery (see below). Alpha-blockers work for about 6 to 9 out of 10 men (depending on the alpha-blocker used and how much). Finasteride works for about 5 to 7 out of 10 men who use it.⁴ Alpha-blockers can reduce AUA symptom scores by 15% to 44% (depending on the medicine used and the amount). Finasteride can reduce symptoms by 25% to 30%.⁴ Are there other reasons you might want to use medicines?	You have mild symptoms. Medicines may not work for you. About 4 out of 10 men will improve without treatment.¹ Watchful waiting does not increase your risk of complications or future surgery. The side effects of medicine may be more bothersome than the symptoms of BPH (see below). You will have to take medicine every day for life. Some medicines are available in generic forms that may cost less, but medicines can be very expensive. Are there other reasons you might not want to use medicines?

**Deciding about 5-alpha reductase inhibitors**
Reasons to use 5-alpha reductase inhibitors	Reasons not to use 5-alpha reductase inhibitors
You have a large prostate. Finasteride can reduce prostate size by 20%.^5,⁶ Finasteride is effective in about 5 to 7 out of 10 men treated.⁴ Finasteride can reduce AUA symptom scores by 25% to 30%.⁴ Finasteride may reduce the risk of acute urinary retention (AUR) and AUR requiring catheterization. Finasteride may reduce the risk of future surgery for BPH.² Finasteride may reduce the risk of recurrent blood in the urine if BPH is the cause.⁵ Are there other reasons you might want to use 5-alpha reductase inhibitors?	Symptom relief may take up to 6 months. Side effects include decreased sex drive, reduced ejaculatory volume, and difficulty getting an erection. Some evidence suggests that these are less effective for symptom relief than alpha-blockers. It can be expensive over a lifetime. Are there other reasons you might not want to use 5-alpha reductase inhibitors?

**Deciding about alpha-blockers**
Reasons to use alpha-blockers	Reasons not to use alpha-blockers
Alpha-blockers are effective in 6 to 9 out of 10 men treated. How well they work depends on which alpha-blocker is used and how much of it is used.⁴ They can reduce AUA symptom scores by 15% to 44%.⁴ They relieve symptoms within 2 to 3 weeks. Some evidence suggests that they are more effective for symptom relief than finasteride.² They can help relieve high blood pressure (potentially eliminating the need to take two medicines). Are there other reasons you might want to use alpha-blockers?	They do not affect prostate size. Side effects include weakness or fatigue; lightheadedness, dizziness, or fainting when standing; a slight decrease in blood pressure; and headaches and nasal congestion. When used alone, they do not reduce the risk of BPH complications that may require surgery. Are there other reasons you might not want to use alpha-blockers?

Using a combination of an alpha-blocker with a 5-alpha reductase inhibitor may help your symptoms more than either medicine alone.^7,⁸

These personal stories may help you make your decision.

Wise Health Decision

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about using medicine for benign prostatic hyperplasia. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

I have mild or moderate symptoms that don't really bother me.	Yes	No	Unsure
I have moderate or severe symptoms that bother me.	Yes	No	Unsure
I understand that my symptoms may come and go or get better or worse.	Yes	No	Unsure
I have a large prostate.	Yes	No	Unsure
I worry about the side effects of medicine.	Yes	No	Unsure
I have tried watchful waiting and/or herbal therapies, and my symptoms are the same.	Yes	No	NA*
I have recurrent urinary retention, recurrent urinary tract infections, kidney problems, bladder stones or infection, or urine in the blood.	Yes	No	NA

*NA = Not applicable

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use or not use medicines for benign prostatic hyperplasia.

Check the box below that represents your overall impression about your decision.

Leaning toward watchful waiting

Leaning toward medicines

Return to the topic Benign Prostatic Hyperplasia (BPH).

References

Citations
Roehrborn CG, McConnell JD (2007). Benign prostatic hyperplasia: Etiology, pathophysiology, epidemiology, and natural history. In AJ Wein, ed., Campbell-Walsh Urology, 9th ed., vol. 3, pp. 2727–2765. Philadelphia: Saunders Elsevier.
Webber R (2006). Benign prostatic hyperplasia, search date May 2005. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.
Presti JC, et al. (2008). Benign prostatic hyperplasia (BPH) section of Neoplasms of the prostate gland. In EA Tanagho, JW McAninch, eds., Smith’s General Urology, 17th ed., pp. 348–370. New York: McGraw-Hill.
Paterson R, Goldenberg L (2001). Benign prostatic hyperplasia. In J Teichman, ed., 20 Common Problems in Urology, part 2, pp. 185–198. New York: McGraw-Hill.
Barry MJ (2007). Benign prostatic hyperplasia. In DC Dale, DD Federman, eds., ACP Medicine, section 10, chap. 13. New York: WebMD.
Kirby R, Lepor H (2007). Evaluation and nonsurgical management of benign prostatic hyperplasia. In AJ Wein, ed., Campbell-Walsh Urology, 9th ed., vol. 3, pp. 2766–2802. Philadelphia: Saunders Elsevier.
McConnell JD, et al. (2003). The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. New England Journal of Medicine, 349(25): 2387–2398.
Roehrborn CG, et al. (2008). The effects of dutasteride, tamsulosin and combination therapy on lower urinary tract symptoms in men with benign prostatic hyperplasia and prostatic enlargement: 2-year results from the CombAT study. Journal of Urology, 179(2): 616–621.

Credits

Author	Monica Rhodes
Editor	Kathleen M. Ariss, MS
Associate Editor	Pat Truman, MATC
Primary Medical Reviewer	E. Gregory Thompson, MD - Internal Medicine
Specialist Medical Reviewer	Christopher G. Wood, MD, FACS - Urology/Oncology
Last Updated	March 24, 2008

Author:	Monica Rhodes	Last Updated: March 24, 2008
Medical Review:	E. Gregory Thompson, MD - Internal Medicine Christopher G. Wood, MD, FACS - Urology/Oncology
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