Moderate symptoms of benign prostatic hyperplasia. Part 2
Questions and Answers
1. Have similar studies been done comparing drug treatment to surgery or watchful waiting?
No. It’s very unlikely that anyone could get funding for such a study. It’s pretty clear that surgery is much more effective than medication.
2. Can watchful waiting really be considered a treatment that can succeed or fail?
Yes, there’s a huge amount of improvement that occurs in watchful waiting over time, particularly if they do the behavioural approaches you described – avoid medications that make it worse, stay away from caffeine and alcohol, don’t drink fluids in the evening and empty the bladder before going to bed. These things seem to have a significant effect on a lot of men. Also, benign prostatic hyperplasia symptoms come and go naturally – you see that even with placebo, things just get better. If you’re not really badly bothered, watchful waiting and drugs are reasonable alternatives, but if you’re badly bothered, you’re probably wasting your time with these options.
3. Does the age of the patient make watchful waiting more or less appropriate?
Ironically, it’s in the younger patients that more thought should be given about drug treatment, because they have so much more time to pile up the costs and side effects. If you’re young and choose medication, you have to understand that you’re potentially going to be on them for the rest of your life. The price of the drugs will surpass that of surgery after a few years, and you still don’t know if you’ll eventually need surgery anyway. I always recommend that, if a young man is going to start on the drugs, he do so for two or three months, then stop for a couple of months and see if it makes any difference, because so many men will get better anyhow – it may be no better than a sugar pill. They should stop and start a few times before deciding to commit themselves to lifelong drug therapy, to make sure it’s working. For an older man with a more limited life expectancy, he has less time to benefit from surgery and more risk for complications. Therefore, drugs may actually make more sense in an older man. This is the opposite of what’s going on in most practices.
4. Can you explain the discrepancy between the men’s evaluation of sexual performance and that of their partners?
The real point is that neither surgery nor watchful waiting differed in their effect on potency. If you looked at those men who were actually impotent, their spouses were more likely to agree. But it’s not unusual for the man and the wife to have different perceptions of sexual function. The disagreement wasn’t significant.
Editorial Commentary
This is the only study that’s ever looked at TURP, which is a very common surgery, and compared it to watchful waiting. We looked at people for at least three years and up to six years. The study shows that, particularly for men who are bothered, surgery is likely to be very beneficial and not likely to result in impotence or incontinence. Prior to this, all the studies showing that surgery results in impotence were not controlled. Many older men become impotent anyway, and then blame the surgery – you always want to look back and blame something. In this study, we looked at that very carefully and found no evidence that it’s true.