Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, M.D.
 12 January 2005

THE PROBLEM OF THE PROSTATE

            The most common health problem that men experience involves the prostate gland. This gland is located immediately in front the bladder and is wrapped around the tube called the urethra that empties the bladder.  As men grow older, the prostate gland tends to get bigger and squeezes the tube emptying urine from the bladder. This makes emptying the bladder more difficult.  The urine stream gets smaller.  Often times, the gentleman has to push and squeeze with the abdominal muscles in order to empty his bladder.  The most common cause of this problem is called benign prostatic hypertrophy or BPH for short.  Previously, there was only surgery to help with this.  Now there are medications that can reverse the problem or even prevent it from ever occurring.

            The story of how these medications were discovered and how they work dates back to 1786.  It was in that year that Dr. John Hunter, a surgeon living in Scotland, noted the effects of castration on cattle.  It may not be of much interest to most people but bulls have a prostate gland too.  When a bull is changed into a steer by castration, the former bull’s prostate gland begins to shrivel up and disappear.  Why Dr. John Hunter felt the need to look at this type of problem I am not sure.  But it is recorded in his notes from 220 years ago.  In the 1930’s, Dr. Ruzicke and Dr. Butenandt received the Nobel Prize for isolating and characterizing the major male hormone, testosterone.  For many years it was thought that testosterone was the male hormone that made the prostate get bigger.  It turns out, that is isn’t true at all.

            By an hereditary quirk of nature, there are families in which the men lack a body protein called 5-alpha-reductase.  This protein changes testosterone into dihydro-testosterone.  It turns out that dihydro-testosterone is the hormone that actually makes the prostate grow.  By the way, it also causes male pattern baldness. Thus, the men who were afflicted (blessed) with a 5-alpha- reductase deficiency never grew a prostate and didn’t develop male pattern baldness.  They were normal in all other ways and were able to have children.  All of this was learned in the 1970’s.

            Pharmaceutical companies hire chemists and research scientists who spend a lot of time thinking about this type of thing.  These scientific types reasoned that there might be a way to block the 5-alpha-reductase protein and thereby prevent or reverse the prostate from growing as man age.

            In 1992, the Merck Pharmaceutical Company introduced finasteride (Proscar, Propecia).  Proscar ($82/month) was directed to treat enlarged prostate glands and came in the 5 mg size.  Propecia ($56/month) was designed to prevent hair loss and was only the 1 mg size.  Both drugs have very slow effects over several years time.  The man who has difficulty starting his urinary stream or difficulty with retaining his urine may take 2-3 years before the prostate shrinks down small enough to allow his stream to be more normal.  This is a long time to wait even though the drug is eventually effective.  In regard to the hair loss problem, many men become discouraged because they can’t see what they don’t lose.  They take the pill called Propecia to prevent hair loss and expect to see more hair.  That doesn’t happen even though they may not be losing more hair.  Propecia has been a hard sale.

            In 2002, a new product called dutasteride (Avodart) ($80/month) was introduced on the market.  This product was more potent and achieved faster results than the finasteride that had been introduced 10 years earlier.  There are studies directed to determine if either of these products can prevent cancer of the prostate.  Preliminary trials have indicated a 24% decrease in the incidence of cancer of the prostate in men taking dutasteride.  To this time, the Federal Food and Drug Administration has not approved either of these products as a prostate cancer preventive but the data is accumulating and the recommendation for cancer prevention is expected in the future.

            Thus, what should a man do?  For those men who are having difficulty with their urinary stream and need relief right now, effective medications include doxazosin (generic price $15/month) (Cardura) (brand name price $43/month) or terazosin ($15/month) (Hytrin) ($45/month).  These medications were originally introduced as blood pressure pills but were found to have the fringe benefit of making it easier for a man to urinate.  They have the side effect of perhaps dropping blood pressures too low.  There are also more expensive products such as alfuzocin (Uroxatral)($56/month) or tamsulosin (Flomax) ($59/month).  These products do not lower the blood pressure but do make the urine flow easier for a man.  But none of these products actually reduce the size of the prostate gland.

            For those men who would like to avoid the problems of prostate gland obstruction in the future, either finasteride or dutasteride are an appropriate and safe medication to use.  They seem to reduce the size of the prostate, decrease the incidence of cancer of the prostate, and delay or slow male pattern baldness.  For those men who would like these benefits, these medications are a reasonable choice.  They are a very hard sell because most 50 year old men still have some hair, maintain their urine stream and don’t have cancer of the prostate.  If they start taking the medication, they will never know what they didn’t get.  Like all preventive measures, this just isn’t very satisfying for most men but is sure is nice for those that choose the preventive route and maintain their health.

            Of course, for those men who want to feel the benefit of the treatment they receive there are always those wonderful prostate surgeries that become necessary when the prostate gets too big and there is not time for medication to work..  And talk about side effects.  Those prostate surgeries can leave a man with a permanent leak and loss of sexual function.  The medications do not do either.  The healthcare providers at your local clinics are aware of these considerations and can offer advice to men on how to deal with prostate problems early before surgery becomes necessary.