Some men can live with their symptoms of prostatism. They wake up a few times at night, but they go right back to sleep without being bothered. They may have to wait for the urine to come out, the urine may come out slowly and even stop and start, but they can live with this. These men may be found to leave a moderate amount of urine left behind after voiding, but it stays fairly stable over time and is not even noticed by the individual.
These men may not wish any treatment for their prostatism. If the kidneys function normally, the urine is not infected, there are no bladder stones, and their is no incontinence, there is often no immediate danger. Watchful waiting may be an attractive treatment option.
However, watchful waiting does not mean complacency. The patient is seen regularly. A thorough history, physical examination, measure of urinary flow, measure of residual urine, and urinalysis are performed at regular intervals. A deterioration of bladder function, worsening of symptoms, or complication of prostatism should lead to an abandonment of watchful waiting and the institution of some type of therapy to halt or reverse the problems.
What are the complications and risks of untreated bladder outlet obstruction? About 1% of men with prostatism will go into urinary retention (inability to void at all) each year. Some men will develop a urinary tract infection. Some men will have worsening of their kidney function. Some will develop bladder stones. An unknown percentage of men will have their bladders decompensate over time, resulting in worsening of bladder function.
Probably the most common complication of watchful waiting is progressive worsening of voiding symptoms. The man may not be able to get a good night's sleep because of frequent awakenings to void. Some men may be afraid to go out of the house for long periods of time for fear of "being caught" out of reach of a bathroom. When the symptoms of prostatism become more bothersome, it is time to abandon watchful waiting and initiate therapy.
Medical, or drug, therapy has become an increasingly popular treatment for men with voiding symptoms secondary to an enlarged prostate. The two main types of drug treatments are alpha-blocking drugs and hormonal drugs.
The smooth muscle cells in the prostate play a large role in the development of prostatism. These smooth muscle cells are under the control of the adrenergic nervous system. Alpha-blocking drugs block the adrenergic nervous system. This in turn leads to relaxation of muscle tone in the prostate and the prostate capsule. In addition, these medications cause relaxation of the bladder neck, which is the opening of the bladder.
Certain alpha-blocking medications have the advantages of being long acting and having actions specific to the prostate. These medications have become the most popular for treating prostatism. These drugs are tamsulosin (Flomax), terazosin (Hytrin), and doxazosin (Cardura). These three medications are fairly similar in their effectiveness, and reduce symptoms by about 50% in the average patient. There are some side effects, such as a decrease in blood pressure when arising from bed (2-4%), dizziness (9-16%), feeling tired (7-8%), headache (5-9%), and nasal congestion (2%).
Hormonal therapy is based on the fact that male hormones are necessary for prostatic growth. The male hormone testosterone is converted to dihydrotestosterone (DHT) in the prostate by the enzyme 5-alpha-reductase. DHT is the hormone that maintains prostate growth. Finasteride (Proscar) blocks the conversion of testosterone to DHT, which leads to a 20% reduction in the size of the prostate, and a 30% reduction in symptoms in the average male. Finasteride works best in men with large prostates, and a man must take this drug for at least six months before the maximal effect is seen. There are a few side effects, such as impotence (3-4%) and decreased libido (3-4%).