Medical treatment of the large prostate

Abstract

Medical management of men with prostates of over 100 mL aims to improve symptoms of bladder outflow obstruction and resulting overactive bladder and to prevent urinary retention and the need for surgery. Most of the well-known, large prospective studies did not analyse sub-groups of men with prostates of this size. Alpha-blockers such as Tamsulosin and Alfuzosin can be used to improve urinary symptoms and an effect should be evident after four weeks. 5-a reductase inhibitors such as Dutasteride and Finasteride may improve symptoms after several months of treatment but their main role is in preventing acute urinary retention and the need for outflow surgery. They may also be used to treat haematuria arising from the prostate and to reduce bleeding before trans-urethral resection of the prostate. Overactive bladder symptoms are common in men with large prostates and can be treated with anti-muscarinics such as Oxybutynin/Solifenacin or β3 agonists such as Mirabegron. These medications do not appear to significantly increase post void residual volumes but there is not enough evidence to guarantee their safe use in men with high residuals. They can be used in combination with alpha-blockers in a single formulation (Vesomni) for men with mixed symptoms. Phosphodiesterase 5 inhibitors such as Tadalafil are now recommended for treatment of lower urinary tract symptoms. They are similar in effectiveness as a-blockers for symptom improvement and are particularly useful in treating co-existing erectile dysfunction.