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Chance to Sleep Through the Night
By GINA KOLATA
NY Times, September 23, 2002
As surely as middle age brings on a receding hairline and, all too
often, a growing waistline, it also brings, for most men, an embarrassing
problem. Its medical name is B.P.H., for benign prostatic hypertrophy, or
hyperplasia and, as its name implies, it is an enlargement of the prostate
that is not caused by cancer. It shows up as a problem with urinating.
"Most men, by the time they get into their 50's and 60's, have a
decrease in urinary function," said Dr. Albert G. Mulley Jr., a
specialist in internal medicine and medical decision making at the
Massachusetts General Hospital. "A lot of men won't talk about it,
but the stream isn't what it used to be. It becomes awfully hard to empty
your bladder and not to feel like you have to empty it again. There's lots
of dribbling."
What can men do about it?
About a decade ago, the choices were bleak. "Men lived with their
symptoms, and if they got really bad, they had surgery," said Dr.
Peter C. Albertsen, a urologist at the University of Connecticut Health
Center.
Now, men with moderate symptoms are treated with medications and most
get relief. The operation, which involves cutting much of the tissue
inside the prostate, is for men who cannot be helped any other way.
Dr. John D. McConnell, a urologist at the University of Texas
Southwestern Medical Center in Dallas, ticked off today's options:
watchful waiting, medications, a half-dozen minimally invasive surgeries,
traditional surgery and variations on those themes.
When a man visits Dr. McConnell about urination problems, he said, the
first question he asks is how bothersome are the symptoms. "Many men
with B.P.H. have symptoms, but they may just be getting up once a night to
urinate or they may just have a slow urine stream. Often they just need
reassurance that they don't have prostate cancer," he said.
The condition, in fact, has nothing to do with cancer. The prostate
gland, which surrounds the tube that carries urine from the bladder to the
penis, is about the size of a walnut. It often enlarges in middle-aged and
older men, squeezing and narrowing the urethra while putting pressure on
the bladder. The gland can continue to grow after symptoms of B.P.H.
emerge, worsening urinary problems, but often it does not.
A new study by the National Institutes of Health indicates that only 20
percent of men with moderate symptoms progress to more severe ones over a
five-year period.
MOST men who are seriously bothered by their symptoms opt for
medication, urologists said. These are men who get up repeatedly at night
to urinate, or who can't get through a meeting without rushing to the
men's room.
There are two types of drugs that can help. The alpha blockers relax
muscles that contract the prostate and the neck of the bladder, allowing
urine to flow more freely. Two alpha blockers, doxazosin and terazosin,
are available as generics. Originally developed as drugs to treat high
blood pressure, they were later discovered to be effective against B.P.H.
Their disadvantage is that doctors have to start with a low dose,
gradually increasing it so the men do not get dizzy from excessively low
blood pressure. A third drug, tamsulosin, also known as Flomax, was
developed more recently for B.P.H., and avoids that low blood pressure
problem, Dr. McConnell said.
A lot of men who take alpha blockers report a 50 percent reduction in
their symptoms, as measured on a scale that asks questions like how
frequently they urinate during the day and at night, and how often their
bladder empties incompletely.
Another type of drug, finasteride, also known as Proscar, actually
shrinks the prostate about 20 percent. By itself, Dr. McConnell said, it
is not quite as useful as an alpha blocker. But in the long run, it
reduces the risk that B.P.H. will progress. "If the goal is to
prevent or delay progression, the combination of the two therapies is
better than either alone," he said.
New data from the N.I.H. study predict which men with B.P.H. are likely
to get worse over the years. A man's prostate must clearly be enlarged
upon physical examination and he must have slightly elevated levels of a
protein, P.S.A., whose levels soar when a man has prostate cancer.
Some men take an alpha blocker, then add finasteride, and still find
their symptoms intolerable. For them, the only thing left is to remove the
interior of the prostate gland.
Doctors can do this in their offices, with a variety of methods that
use radio-frequency energy to essentially burn and destroy the tissue. The
complications are a 10 to 30 percent chance that a man will be unable to
urinate for a day or so afterward, requiring a catheter, and about a 50
percent chance that he will experience short-term symptoms, including a
burning sensation when he urinates and an increased frequency of
urination. The question hanging over this expensive treatment — it can
cost $3,000 to $6,000, Dr. McConnell said — is its long-term outcome.
"There is not a single, well-designed long-term study that
demonstrates five-year success rates," he said.
Finally, there is an operation, with a surgeon removing the tissue in
the prostate.
"It is still the single, most-effective treatment," Dr.
McConnell said. But it does carry slight risks of temporary consequences,
like narrowing of the urethra or bleeding. These days, only about 10 to 15
percent of men end up needing it.
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