What is the treatment for a prostate size exceeding 50 cubic centimeters (cc)?

Treatment for Prostate Size Exceeding 50 cc

For prostate size exceeding 50 cc, the recommended treatment is a 5-alpha reductase inhibitor (5ARI) such as finasteride or dutasteride, typically in combination with an alpha-blocker for optimal symptom management. 1

Initial Medical Management

First-line Therapy

• Alpha blockers (alfuzosin, doxazosin, tamsulosin, terazosin) for rapid symptom relief
• 5-alpha reductase inhibitors (5ARIs) for patients with prostate >30cc, especially indicated for prostates >50cc
  • Finasteride 5mg daily or Dutasteride 0.5mg daily
  • These medications reduce prostate volume by 24-28% after 24 weeks of treatment 2

Combination Therapy

• Alpha blocker + 5ARI is particularly appropriate for large prostates (>50cc) 1
• This combination provides immediate symptom relief (from alpha blocker) and addresses the underlying enlarged prostate (via 5ARI)
• Combination therapy reduces the risk of disease progression by 67%, significantly better than either medication alone 1

Benefits of 5ARIs for Large Prostates

5ARIs provide several important benefits for patients with prostates >50cc:

1. Reduction in prostate volume:

   • Dutasteride reduces prostate volume by 26.7% after 24 months 3
   • Finasteride reduces prostate volume by 17.9% after 4 years 4

2. Reduced risk of complications:

   • 57% reduction in acute urinary retention risk with dutasteride 3
   • 57% reduction in acute urinary retention risk with finasteride 4
   • 48-55% reduction in BPH-related surgery risk 4, 3

3. Symptom improvement:

   • Significant improvement in AUA Symptom Index scores
   • Improved maximum urinary flow rates

Surgical Options When Medical Therapy Fails

If medical therapy fails or if the patient has complications such as recurrent urinary retention, recurrent UTIs, renal insufficiency, recurrent gross hematuria, or bladder stones, surgical intervention is recommended 1:

1. Transurethral Resection of the Prostate (TURP): Gold standard surgical treatment

2. Laser Enucleation (HoLEP or ThuLEP): Suitable for all prostate sizes, better for patients on anticoagulation

3. Open Prostatectomy: May be necessary for very large prostates (typically >80-100cc)

Monitoring and Follow-up

• Evaluate response to therapy within 4-12 weeks after initiating treatment 1
• Reassess IPSS score and consider PVR and uroflowmetry during follow-up
• Monitor PSA: 5ARIs reduce PSA by approximately 50% after 12 months; establish new baseline after 3-6 months of treatment 1
• Annual follow-up if treatment is successful

Important Considerations

• Sexual side effects (decreased libido, erectile dysfunction) occur in 1-8% of men taking 5ARIs 5
• These side effects are generally reversible and often diminish after the first year of therapy 1
• 5ARIs are ineffective in patients without prostate enlargement 1
• Neglecting to establish a new PSA baseline after starting 5ARI therapy can lead to inaccurate monitoring of prostate health 1

For prostates >50cc, the evidence clearly supports using 5ARIs (alone or in combination with alpha blockers) as the cornerstone of treatment to reduce prostate volume, improve symptoms, and prevent disease progression.