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, medication, and surgery. Generally, watchful waiting or medications are considered first, and then surgery. This Decision Point focuses on deciding between watchful waiting and medications.
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 medication 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. However, 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; there is a 31% to 55% chance that they will improve without treatment.¹
You may find the side effects of medication more bothersome than your BPH symptoms.
Medications may decrease the risk for acute urinary retention and a future surgery for BPH.^2,³
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 50 experience some symptoms.
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; nor does it 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 medication to relieve your symptoms. Options include:
Alpha-blockers, such as terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Uroxatral), and prazosin (Minipress), which relax muscle tissue.
5-alpha reductase inhibitors, such as finasteride (Proscar) or dutasteride (Avodart), which shrink the prostate.
The decision about whether to use medications 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. However, 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. Click here to determine the severity.
Deciding about using a medication to treat BPH
Reasons to use medication Reasons not to use a medication 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).
Medications are effective in 54% to 86% of men treated (see below).¹
Medications can reduce AUA symptom scores about 31% to 51% (see below).¹

Are there other reasons you might want to use medications?

You have mild symptoms.
Medications may not work for you.
There is a 31% to 55% chance that symptoms will improve without treatment.¹
Watchful waiting does not increase your risk of complications or future surgery.
The side effects of medication may be more bothersome than the symptoms of BPH (see below).
You will have to take medications for life.

Are there other reasons you might not want to use medications?
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%.^4,⁵
Finasteride is effective in 54% to 78% of men treated.¹
Finasteride can reduce AUA symptom scores by 31% to 50%.¹
Finasteride may reduce the risk of acute urinary retention (AUR) and AUR requiring catheterization.²
Finasteride may reduce the risk of future surgery for BPH.^2,³
Finasteride may reduce the risk of recurrent blood in the urine if BPH is the cause.⁴
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 59% to 86% of men treated.¹
They reduce AUA symptom scores about 50%.²
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 medications).
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?
A U.S. National Institutes of Health (NIH) study found that combining finasteride with the alpha-blocker doxazosin (Cardura) reduces the chances of symptoms getting worse, urinary retention, and the need to have surgery. The combination of the two medicines worked better than either medicine alone or when compared with a placebo.⁶
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 medication 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 medication. Yes No Unsure
I have tried watchful waiting and/or herbal therapies, and they didn't help. 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 medications for benign prostatic hyperplasia.
Check the box below that represents your overall impression about your decision.

Leaning toward watchful waiting

Leaning toward medications

Return to the topic Benign Prostatic Hyperplasia (BPH).


Author:	Ralph Poore	Last Updated March 31, 2006
Medical Review:	Martin Gabica, MD - Family Medicine Christopher G. Wood, MD, FACS - Urology/Oncology
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