What are the treatments for prostatic problems?

Treatment Options for Prostatic Problems

Treatment for prostatic problems should be tailored based on the specific condition, with benign prostatic hyperplasia (BPH) and prostate cancer requiring distinctly different management approaches.

Benign Prostatic Hyperplasia (BPH) Treatment

Medical Therapy

• Alpha-blockers (alfuzosin, doxazosin, tamsulosin, terazosin) are first-line treatments for moderate BPH symptoms, improving symptoms within 4 weeks 1
• 5-alpha reductase inhibitors (finasteride, dutasteride) are indicated for prostates larger than 30cc, reducing prostate size, improving symptoms, and decreasing risk of acute urinary retention 1, 2
• Combination therapy with alpha-blocker and 5-alpha reductase inhibitor is recommended for large prostates with moderate to severe symptoms to reduce risk of disease progression 1

Surgical Management

• Surgery is recommended for patients with:

  • Refractory urinary retention who have failed catheter removal attempts
  • Renal insufficiency due to BPH
  • Recurrent UTIs or gross hematuria due to BPH
  • Bladder stones due to BPH 3

• Transurethral Resection of the Prostate (TURP) remains the benchmark surgical therapy for BPH, involving removal of the prostate's inner portion via endoscopic approach 1

• Other surgical options include minimally invasive procedures, transurethral incision of the prostate (TUIP), and laser procedures 1

Prostate Cancer Treatment

Localized Disease Management

• For low-risk disease (T1-2a, Gleason <6, PSA <10 mg/l), options include:

  • Active surveillance with selected delayed intervention 3
  • Radical prostatectomy 3
  • External beam radiotherapy 3
  • Brachytherapy with permanent implants 3

• For intermediate-risk disease, options include:

  • Radical prostatectomy or radiotherapy 3
  • Neoadjuvant and concurrent ADT for 4-6 months with radiotherapy 3

• For high-risk or locally advanced disease, options include:

  • External beam radiotherapy plus hormone treatment 3
  • Radical prostatectomy plus pelvic lymphadenectomy 3

Advanced/Metastatic Disease Management

• Continuous androgen deprivation therapy (ADT) is recommended as first-line treatment for metastatic, hormone-naïve disease 3

• ADT plus docetaxel is recommended for metastatic hormone-naïve disease in men fit for chemotherapy 3

• For castrate-resistant prostate cancer:

  • Abiraterone or enzalutamide for asymptomatic/mildly symptomatic men 3
  • Radium-223 for bone-predominant, symptomatic disease without visceral metastases 3
  • Docetaxel for metastatic disease 3

Prostatitis Management

• Bacterial prostatitis requires antimicrobial therapy, with fluoroquinolones as preferred agents due to their favorable penetration into prostatic tissue 4

• For chronic prostatitis:

  • Alpha-blockers show greater response with longer durations of therapy 4
  • Anti-inflammatory agents may be necessary in combination with or after antimicrobial agents 4

Important Considerations

For BPH Treatment

• Monitor patients 4-12 weeks after initiating treatment, assessing symptom scores, post-void residual, and uroflowmetry 1
• Consider lifestyle modifications including reducing fluid intake by 25%, adopting a diet rich in fruits and vegetables, moderate alcohol intake, regular exercise, and weight loss for overweight patients 1

For Prostate Cancer Treatment

• Staging and risk assessment are crucial for treatment selection 3
• PSA monitoring is essential following radical prostatectomy, with salvage radiotherapy to the prostate bed for PSA failure 3
• Early ADT is not routinely recommended for men with biochemical relapse unless they have symptomatic local disease, proven metastases, or PSA doubling time <3 months 3

Common Pitfalls to Avoid

• Primary ADT alone is not recommended as standard initial treatment of non-metastatic prostate cancer 3
• Immediate post-operative radiotherapy after radical prostatectomy is not routinely recommended 3
• Prostatic stents for BPH should be reserved only for high-risk patients with urinary retention 1
• For BPH patients receiving antiandrogen therapy, breast bud irradiation (8-15 Gy in 1-3 fractions) should be given 1-2 weeks before initiation to prevent painful gynecomastia 3

By following these evidence-based approaches, most prostatic problems can be effectively managed with appropriate consideration of disease characteristics and patient factors.