Treatments for BPH

Treatments for BPH – So the relaxers are okay. They are very commonly used. God, they throw them out like candy. I mean, I watched a movie with Jack Nicholson the other night, and he said, “I’m on Flomax.” during the movie. I don’t know if he’s really on it, but, so, that’s the relaxers. They’re simple, it’s an easy script, have a nice day. And then you’ve got the shrinker pills. Right, so these are the 5 alpha-reductase inhibitors. 5 alpha-reductase is an enzyme which converts testosterone to dihydrotestosterone within the prostate cell.

And so what does that do? If you block that conversion you don’t have as much of the active, the dihydro, impacting the prostate cell and what happens then is the prostate cells don’t grow. So they recede in their growth and over time fewer cells actually are produced, and because the cells are the building blocks of these big prostates, they themselves, the prostates, also recede in size. So, the idea is that a smaller prostate is typically a less bothersome prostate.

So for treatments for BPH we’ll often use these drugs in combination with the alpha-blockers, but there are some unique problems with these drugs. Yeah, so it takes a while for the drugs to shrink the prostate. 3-6 months. 3-6 months until your urine flow is a little bit better, and what are the side effects—God this is a notorious class of drugs—what are the side effects you don’t like with the shrinkers? So, not only is there a problem with ejaculation.

In this case, not related to the squeeze of the mechanism, as is with the alpha-blockers, but in this case related to the fact that these glands, these glandular cells in the prostate are the cells where semen is produced and in essence the semen production just stops. So men on 5 alpha-reductase inhibitors don’t have any forward ejaculation, but it’s not because the mechanism is paralyzed; the factory has been shut down.

And that’s a bother to some men, but also in these drugs, there’s a higher incidence of erectile dysfunction, a loss of libido or sexual drive, and again we’re starting to begin to see other more serious potential side effects like changes in the metabolism of glucose and lipids, and you know things that we need to be healthy. So these drugs may actually impact organs outside the prostate. Do you want to talk about the prostate cancer prevention?

Well we can talk about… I mean, the shrinkers… There’s a theory that the shrinkers actually reduce the risk of prostate cancer. So what they do, without question, is they reduce the PSA production. We’ve known this and, in fact, a PSA six months into the treatment with this kind of drug will typically be 50% of what it was before. It’s a bit of a smoke and mirrors situation. It doesn’t mean you necessarily have that degree of improvement in a cancer diagnosis or less likely to have cancer.

But that was tested in two major trials—the cancer prevention potential—and in both trials with each of the two drugs in this class finasteride and dutasteride (or Proscar and Avodart) there was some evidence of cancer prevention. The downside or the flip side is that in those patients who got prostate cancer in those trials, they had a higher risk of a higher grade prostate cancer, and all the packaging labeling talks about it, and you know we have to appropriately counsel our patients that that’s a possibility even though many of us think it’s sort of an artifact of the studies.

But I think in the end, because of this sort of secondary finding, these drugs aren’t in widespread use for prostate cancer prevention. Yeah, but, you know, we talked about your relaxers and your shrinkers, and now you can even buy a pill that combines both. Yep. Right. Yep. You can put a relaxer and a shrinker in one pill and take it. Take the pill apart and two pills fall out of it. That’s an expensive way to do it. There’s also just generic options and most of us do it that way.

You just don’t seem very excited about these pills, and I know you’re not a big pill pusher. I know you do some procedures, but you just don’t seem excited about them. I think I’ve just done it long enough to know that we get what we get and it’s not always enough. So, and I think that they almost lull patients into this sense that everything is okay because, “yeah, I don’t get up as many times at night,” or what have you. Even if we’re taking away the side effects, the impact of these therapies is not a home run.

And so, some guys need a home run. Some guys just need a single and they’ll do fine, but some guys really need more than what these pills can offer. And when you say I’m not excited about it, I write these all day long because patients want them. Yeah. But then it’s interesting to me to see how many of them stop them. You know? Yeah, yeah. And I’m worried about the guys who stop them, say “well that guy didn’t know what he was doing,” and don’t come back and then on goes the bladder deterioration. Right, and then the kidney problems and all the other bad stuff that you talked about.

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