When it comes to treating enlarged prostates, a condition that affects more than half of American men over age 60, less may be more.
New federal guidelines announced Tuesday say that subjecting patients with enlarged prostates to less surgery, medications and diagnostic tests will improve care and reduce overall costs.
“The most important central point of these guidelines is that the decision about treatment should really rest in the patient’s hands,” said Dr. John McConnell, chief of urology at the University of Texas Southwestern Medical School in Dallas.
For many men the best choice will simply be watchful waiting, said McConnell, who headed the panel of medical experts that developed the guidelines for the U.S. Public Health Service’s Agency for Health Care Policy and Research.
“We realize that the guidelines will be somewhat controversial,” McConnell said. “They question the traditional role of diagnostic tests and the need for medical or surgical treatment in many cases.”
Instead of assessing patients and recommending treatments, doctors should focus more on informing their patients about the risks and benefits of no treatment as compared to surgery or drugs and then letting patients decide what’s best for them, he said.
An enlarged prostate, or benign prostatic hyperplasia, occurs when the gland grows larger with advancing age, affecting 90 percent of men by age 85.
The prostate is a walnut-sized gland surrounding the urethra at the base of the bladder. Its main purpose is to make the fluid that carries sperm. Enlargement does not involve cancer, but squeezes the urethra, sometimes causing urination problems.
Symptoms include frequent urination, especially at night; straining to urinate; a weak or intermittent urine stream, and a feeling that the bladder has not completely emptied. In some men enlargement can lead to such serious problems as inability to urinate, kidney infections and bleeding.
Many men will never have more than mild or moderate symptoms, McConnell said.
“If a patient only has mild symptoms he should be managed by watchful waiting,” McConnell said. “If the patient has moderate symptoms, then it becomes appropriate to discuss treatment options with him, including medications. Surgery is very effective, but it should be reserved for severe cases.”
Nearly 300,000 men undergo surgery for enlarged prostates each year at a cost of $2 billion, half of which is paid by Medicare. The most common surgery, called transurethral resection of the prostate (TURP), involves cutting out some of the enlarged prostate with a device inserted through the urethral tube in the penis.
Complications from surgery include a one in 100 chance of urinary incontinence, a small risk of impotence and a 0.5 to 1.5 percent risk of death, depending on the patient’s age, McConnell said.
Less frequently used, but almost as effective as TURP, is another surgical procedure called transurethral incision of the prostate. Incisions in the prostate causes it to retract. It is far cheaper than TURP because it is an outpatient procedure. Both procedures are between 75 and 96 percent effective in relieving symptoms.
Two drugs used to shrink the prostate are finasteride and alpha-blockers and they are between 54 and 86 percent effective, McConnell said. But these drugs can cause such side effects as dizziness, fatigue, headaches, lowered sex drive and impotence, he said.
The guidelines also advise against the routine use of two diagnositc tests, cystoscopy, which involves the use of a tube to visualize the bladder, and kidney X-rays.
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