What role do 5-alpha reductase inhibitors play in treating BPH?
5-alpha reductase inhibitors hold principal significance in the treatment of benign prostatic hyperplasia (BPH), which is an enlarged prostate gland causing frequent urination, straining while urinating, and a weak flow of urine. 5-alpha reductase inhibitors work by blocking the hormone dihydrotestosterone (DHT), which contributes significantly to prostate enlargement.
5-alpha reductase inhibitors work in the following way in treating BPH:
1. Mechanism of Action
Production of DHT: The enzyme 5-alpha reductase converts testosterone to produce dihydrotestosterone (DHT). DHT is a highly active androgen (male hormone) that promotes prostate cell growth. In BPH, the levels of DHT in the prostate are elevated, causing the prostate gland to enlarge.
Mechanism of action of 5-alpha reductase inhibitors: These drugs work by inhibiting the activity of the 5-alpha reductase enzyme. By doing so, they reduce the production of DHT in the prostate gland and other tissues.
Reduced prostate size: Since there’s less DHT, the prostate shrinks gradually. This causes dramatic relief of the symptoms of BPH, as the urethra pressure (from which urine exits) is reduced, leading to increased urinary stream.
2. Generic 5-alpha reductase Inhibitors
Finasteride: This is a well-established 5-alpha reductase inhibitor employed commonly. It directly inhibits type II 5-alpha reductase, the enzyme’s most active isoform in the prostate.
Dutasteride: Dutasteride inhibits type I and type II isoforms of 5-alpha reductase. It may be more potent than finasteride in reducing DHT levels and prostate shrinkage.
3. Benefits in BPH Treatment
Prostate shrinking: 5-alpha reductase inhibitors can shrink the prostate by up to 25-30%. This is important because a smaller prostate will ease the symptoms of BPH, such as the need to urinate too frequently or urgently, the inability to start urinating, and poor urine stream.
Improved urinary symptoms: As the size of the prostate shrinks, pressure on the urethra is reduced, leading to improved urinary flow and reduction of BPH pain.
Sustained efficacy: These medications are particularly beneficial for sustaining treatment of BPH. Not only do they improve symptoms, but they may also reduce the need for surgery, such as a transurethral resection of the prostate (TURP).
Prevention of progression of BPH: 5-alpha reductase inhibitors can prevent the progression of BPH, and thus decrease the risk of complications in the form of urinary retention or the need for invasive therapies.
4. Limitations and Side Effects
Slowing onset of action: Unlike drugs like alpha blockers (which provide faster relief of symptoms), 5-alpha reductase inhibitors can take 3 to 6 months to show significant effects on prostate size and symptoms. Patients may need to be patient during the initial phase of treatment.
Sexual side effects: Some patients experience side effects such as loss of libido, erectile dysfunction, and ejaculation disorders. Such side effects are, however, not met by all the users, and they are reversible after discontinuation of the drug or after a reduction in the dosage.
Potential risk of high-grade prostate cancer: There is some evidence that suggests that while 5-alpha reductase inhibitors reduce the overall risk of prostate cancer, they may also increase the risk of high-grade prostate cancer in a small percentage of men. This is one that is being actively studied and will typically be the topic of a discussion between a doctor and a patient before treatment.
5. Combination Therapy
With alpha blockers: At times, 5-alpha reductase inhibitors are used together with alpha blockers (e.g., tamsulosin), which relax the smooth muscles in the prostate and neck of the bladder to improve the flow of urine. While 5-alpha reductase inhibitors cure prostate size, alpha blockers rapidly alleviate symptoms.
6. Who Should Take 5-Alpha Reductase Inhibitors?
Patients with prostatic hypertrophy: These drugs are most effective in men with moderate to severe BPH and an enlarged prostate (typically over 40 grams in volume).
Maintenance therapy: They are most appropriate for men who desire a non-surgical treatment or do not wish to be operated on.
Summary
5-alpha reductase inhibitors play a critical role in the treatment of BPH by lowering hormone levels of dihydrotestosterone (DHT), a hormone that promotes prostate enlargement. By decreasing DHT, these medications decrease the size of the prostate over time, which alleviates symptoms like frequent urination, urgency, and thin stream. While they are effective in the long term, they may take a few months to produce significant results and may have side effects, like sexual dysfunction. In some instances, these drugs are used in combination with other treatments for enhanced effectiveness.
Would you like to learn more regarding how they relate to other therapy medications for BPH?
Surgery is a good choice for the treatment of an enlarged prostate, or benign prostatic hyperplasia (BPH), if other treatments such as medication are not providing sufficient relief. Surgery intends to relieve symptoms caused by an enlarged prostate, such as urinary issues, by reducing the size of the prostate or by removing the obstruction that is preventing the flow of urine. The following are the major surgeries utilized in treating BPH:
1. Transurethral Resection of the Prostate (TURP)
TURP is the most common surgical treatment for BPH. It is the procedure of removing excess prostate tissue that prevents urine flow.
How it’s done: A thin, telescope-like tube with a camera and a cutting instrument is inserted through the urethra (the tube that carries urine from the bladder) into the prostate. The surgeon trims away or cuts out the tissue that is blocking the way with the resectoscope.
Benefits: TURP usually reduces symptoms of BPH significantly, including straining while urinating, needing to urinate often, and having a weak stream of urine.
Recovery: While the procedure is effective, recovery may take a few days in the hospital and some men are left with side effects like urinary incontinence, impotence, or retrograde ejaculation (semen entering the bladder instead of being ejaculated).
2. Transurethral Incision of the Prostate (TUIP)
TUIP is similar to TURP except that small cuts are made in the prostate to open the urethra rather than removing tissue.
How it works: Short cuts in the prostate tissue are created by the doctor such that pressure off the urethra can relieve and allow for urine passage easily. It is most frequently used in men with a smaller prostrate size.
Benefits: TUIP is less invasive than TURP and perhaps safe in men with small prostrate enlargement.
Recovery: TUIP recovery is likely to be shorter than that of TURP, and complications like sexual dysfunction are less probable.
3. Laser Surgery
Laser therapy is another minimally invasive surgical operation for BPH. There are several different laser procedures that involve Holmium laser enucleation of the prostate (HoLEP) and photoselective vaporization of the prostate (PVP).
HoLEP: employs a laser to resect obstructing prostate tissue, similar to TURP but with the advantage of utilizing a laser to remove and coagulate tissue, with less blood loss.
PVP: uses a laser to vaporize the prostate tissue obstructing the urethra.
Advantages: Laser surgery has less bleeding, less time in the hospital, and less time in recovery compared to standard TURP.
Recovery: Recovery time is typically shorter, and the operation may be done on an outpatient basis. Retrograde ejaculation or urinary incontinence that is transient may still occur in some men.
4. Open Prostatectomy
Open prostatectomy is a more serious surgery and is most often reserved for men with very large prostates or for men who have had an unsatisfactory response to other treatment.
How it is done: This procedure involves making an incision through the abdomen or perineum (area between anus and scrotum) to obtain direct access to the prostate gland. The enlarged tissue is removed from this incision.
Advantages: Open prostatectomy is helpful for very large prostates that cannot be treated with less invasive methods.
Recovery: This process has a longer recovery period, typically involving an inpatient stay of several days. It also has a greater risk of complications including infection, bleeding, and sexual dysfunction.
5. Prostatic Urethral Lift (PUL)
PUL is a minimally invasive surgical technique where small implants are utilized to lift and suspend the bulging prostate tissue away from the urethra, easing the obstruction.
How it works: A specialized device is inserted through the urethra to place the implants inside the prostate tissue. The implants prevent the tissue from shifting, creating more space for urine to flow through.
Advantages: The procedure can be done on a same-day basis, and recovery time is minimal. It also has fewer sexual side effects than other surgical interventions.
Recovery: Recovery is typically shorter than with more invasive procedures, but there may be some short-term urinary symptoms, such as urgency or discomfort.
6. Prostate Artery Embolization (PAE)
PAE is a less common, minimally invasive procedure in which small particles are delivered into the blood vessels that supply the prostate, depriving parts of the prostate of blood supply. The prostate tissue gradually shrinks as a consequence.
How it is done: A catheter is inserted into an artery in the groin and guided to the prostate. The embolization material is delivered to shrink the prostate tissue.
Advantages: It is a non-surgical procedure with little downtime. It can be done as an outpatient and is an option for men who may not be candidates for traditional surgery.
Recovery: It has a brief recovery time and few complications but will cause temporary pain or urinary symptoms in some men.
Choosing the Right Surgery
The nature of surgery to be employed depends on several aspects, including:
The size of the prostate.
The level of symptoms.
Patient’s health and desires.
Benefits and risks associated with the procedure.
In most men, surgery may lead to the significant alleviation of symptoms, quality of life, and overall health through obstruction removal from the enlargement of the prostate. As a relief in case medication and lifestyle adjustments fall short, surgical intervention is most often the following course of action.
If you’re considering undergoing surgery for BPH, you should discuss this with your doctor and determine what method is most suitable for your individual case. Do you want to know more about any of these procedures or potential side effects?