The prostate gland is one the more common anatomic structures to cause older men problems. Usually, around age forty, sometimes earlier, men begin having lower urinary tract symptoms (LUTS). LUTS means they develop a weak urine stream, they have to stand and wait for urination to begin (hesitancy), when they urinate the flow will start and stop, or they have to strain to go. These symptoms occur because of the location of the prostate. It sits at the base of the bladder and the tube exiting the bladder, the urethra, runs right through the center of it. As a man ages, his prostate enlarges. The prostate enlarges outwardly and inwardly. Outward enlargement is the large mound the doctor feels on a digital rectal exam. The inward enlargement chokes off, or at least narrows, the urethra, restricting or slowing urine flow and causing the symptoms mentioned earlier.
Another problem associated with benign enlargement of the prostate is incomplete emptying of the bladder after urination. This is called urinary retention and the remaining urine is called residual urine. When urine is in the bladder, the patient continually feels like he needs to urinate (urgency) and does urinate more frequently (frequency). These symptoms occur at night, too (nocturia). After urination, some of the residual urine has the tendency to leak, or dribble, and some men feel like their bladder did not empty completely.
These LUTS (lower urinary tract symptoms) can be very annoying because they interrupt daily activities and keep a man awake at night. Besides an enlarged prostate, these same symptoms can be caused by a kidney stone, a urinary tract infection, or a stricture (a scarred narrowing) in the urethra.
What can a man do about these symptoms? Twenty-five years ago, he almost certainly would have been referred to a urologist for a TURP—a TransUrethral Resection of the Prostate. That’s the old “Roto-Rooter” ream job of the prostate. In this operation, the surgeon used a cutting instrument that was inserted in the penis and passed to the urethra and the core of the prostate and the prostatic urethra were reamed out. This relieved the obstruction, certainly, but left the man with urinary incontinence (frequent leaking) and impotence (erectile dysfunction). These symptoms were life-altering and very annoying. There had to be a better way!
There was and there is. It’s in the form of oral medicine. There are four classes of drugs that are are approved for and prescribed for LUTS. The classes are alpha blockers, PDE-5’s, 5-alpha reductase inhibitors, and anticholinergics. I will explain each class of drug and give trade names of commonly prescribed examples.
ALPHA BLOCKERS: FLOMAX, RAPAFLO, UROXATROL
First line treatment for LUTS. They also can cause a drop in blood pressure when going from sitting to standing. This is especially worrisome at night, and men have passed out while standing to urinate.
PHOSPHODIESTERASE 5 Inhibitors (PDE-5): CIALIS, VIAGRA
These drugs are obviously for the treatment of erectile dysfunction, but in men with enlarged prostates, they have shown a “moderate level” of effect on LUTS, regardless of the presence or absence of of ED.
5-ALPHA REDUCTASE INHIBITORS: AVODART, PROSCAR
These drugs not only relieve LUTS, but also actually reduce the progression of prostatic enlargement. After about 6 months of treatment, 5-ARI’s reach their maximum effect on symptoms. Alpha blockers relieve symptoms right away. Side effects include male breast enlargement. 5-ARI’s reduce PSA by 50%, and reduce the rate of prostate cancer. To be effective, they must be taken long term.
ANTICHOLINERGICS: DETROL, DITROPAN
For men with urinary retention, these drugs help, but they are linked to elevated risk for dementia. They have the potential to worsen urinary retention.
COMBINATION THERAPY:
If the patient has both ED and LUTS, he can be treated with a PDE-5 for ED, and an alpha blocker for LUTS. This combination works well.
Surgery to relieve a urethral obstruction is a thing of the past. Transurethral resections of the prostate (TURP) were done all the time in my early practice days. Now, they are only memories in the minds of the men who were left incontinent and impotent after the procedure. When you have four drug classes you can prescribe, with multiple choices in each class, your therapeutic armamentarium is well equipped. A combination I used was Avodart and Flomax. I would start Avodart and Flomax at the same time. After 6 months, the Avodart had begun to shrink the prostate so I would gradually stop Flomax. Avodart would be continued indefinitely to continue shrinking the prostate.
While all of this was going on, I would continue to check the patient for any possibility of developing prostate cancer. Over the past 30-40 years the treatment of benign prostatic enlargement has changed dramatically and definitely for the better.
References: Skolnik N. How to Manage Benign Prostatic Hypertrophy in Primary Care. Medscape.com, 2026 August 28.
