Tuesday, March 22, 2011

Benign Prostatic Hyperplasia – the Classical Design Fault.

doctorrynne.blogspot.com/2011/03/benign-prostatic-hyperplasia.html

Lets face it, these days very very few patients indeed will consult their doctor without having first consulted Google, Yahoo, Bing and Wikipedia. Love it or hate it (and I suspect most of us are not overjoyed at the prospects of competing with computers) it is now the way of the modern world. It is here and here to stay.

Benign Prostatic Hyperplasia or sometimes, incorrectly, hypertrophy, is of course your classic. It has become a Global industry that stuffs the search engines for thousands of pages. Doctors, surgeons, hospitals, clinics, pharmaceutical and alternative enthusiasts all feed greedily from the bottomless trough that BPH has become. Any wonder then that the middle aged man, finally deciding to consult a real doctor for his dysuria, comes laden down with tonnes of cyber babble and internet rubbish.

The textbooks, but now of course the search engines; tell us that the incidence of BPH is about 50% in men over the age of 50 and more or less leave it at that. Doctors know of course that that is not the full story. In real life we know that the incidence of this pestilence increases with age such that by the age of 80 well over 80% of men will be significantly effected by it. Indeed all men will eventually fall foul to this design fault of nature. For that is what it is – a classical design fault. The urethra should never have been made to pass through a gland that is destined to enlarge with age. All men should be recalled at the age of forty and have this put right!

False dawns, in the form of “office procedures” for the surgical management of BPH continue to come and go. Transurethral Microwave Thermotherapy machines, like Electronic Voting machines, now lie gathering dust in back storeroom of many the teaching hospital. They are embarrassing monuments to the folly of rushing into unproven new technologies. Not only did they not work, they were also quite dangerous. Laser Turps, one suspects, may very well be heading in the same general direction. I will leave to others to inform us about its true efficacy when the dust eventually settles on this still controversial treatment.

If recently introduced minor surgical interventions for the management of BPH have been more gimmicks that genuine then the same can hardly be said about the pharmaceuticals. I refer particularly the alpha blockers of course. In the last twenty years, these medicines have allowed millions of middle aged men across the world, to get on with their lives in relative comfort and without the constant fear of the nightmare that acute urinary retention must be. They have also allowed men to at least postpone, perhaps indefinitely, the indignity in a TURPS procedure with its attending morbidities. Clearly I’m a big fan of the alpha blockers.

Not so however 5-alpha reductase inhibitor. Because Fenasteride has the ability to reduce prostate bulk by some 25% and so relieve some of the symptoms of BPH, this drug is now being pushed as a first line treatment for this benign condition. I believe that this is akin to the old proverbial sledge hammer approach to cracking a nut and I’ll tell you why.

Over the last five years or so, for my sins, I seem to have become more and more involved in the management of sexual dysfunction, not just erectile dysfunction but all sexual dysfunction in man and women. On the internet, hardly a week goes by that I am not being approached by yet another young man recently prescribed Propecia as a “treatment” for male pattern baldness. This drug has the capacity to obliterate their sexuality, not just for the time that they take the drug, but for all time. This vanity treatment can and does condemn many young men to a life sentence of sexual anhedonia, without feeling, desire or function, to otter misery and despair for which, as yet, we have no treatment. If you would like to know more about this you can share in their pain on propeciahelp.com

I believe that potentially toxic medicine like this must be reserved for the indications for which it was first introduced and that is in the management of advanced prostate cancer with metastases. Here, as we all know, it can be life-saving or at any rate life-prolonging. Using it to treat a benign condition like BPH is, in my view, at best questionable. Using it to treat a naturally occurring condition in men like male pattern baldness, is reckless in the extreme.

Finally, a word on tadalafil, the longer acting treatment for erectile dysfunction. Can I refer you to the October issue of the Journal of Urology 2008? Here is reported a study that found tadalafil to be as effective as the alpha blockers in relieving Lower Urinary Tract Symptoms of BPH. Since older men often suffer from both BPH and erectile dysfunction and since tadalafil has been clinically shown to relieve both, might not an argument be made for prescribing daily tadalafil for such men. Two birds with one stone perhaps? I think so.

Dr Andrew Rynne.

March 22nd 2011