Urology/flomax

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Question
dr Goldstein,im 80 years old with enlarged prostate.for 3 months I have taken proscar and Flomax.this combination is helping me ,I used to urinate every hour,now I urinate less and I have a better stream.i am concerned when I come off Flomax if I will be able to urinate or did my prostate get used to the flomax

Answer
Howard, the 2 medications you are taking work on improving your symptoms in different ways.  Proscar's action is by gradually shrinking the prostate gland.  It generally takes 3-6 months for maximum effect to occur.  If it helps you, you should continue the drug as if you discontinue it, the prostate will gradually grow back.  Flomax is one of a group of drugs called alpha blockers.  These medications relax the bladder neck so that thereis less resistance to the flow of urine when the bladder contracts.  They exert their effect in a day or 2.  Also, if the medication is discontinued, their beneficial effect would be lost in a couple days.  The good new, however, is that if you need it, they can be restarted with help expected in a day or so.  Most people do not need both for their BPH so it seems reasonable to see how you do without the Flomax at this time.  If you need it restarted, you can try discontinuing it again after you have been on the Proscar for 6 months.

To follow is some information I have written on BPH that should be of interest to you.

Benign enlargement of the prostate gland (benign prostatic hyperplasia or BPH) occurs to varying degrees in all men as they age.  The prostate surrounds the urinary canal (urethra) just after its connection to the urinary bladder.  Inward growth of the prostate either into the bladder neck (opening) or into the urethra itself can cause difficulty with urinating.  The prostate is checked by digital examination through the rectum.  This gives the doctor an idea as to the size and benignity of the gland.  However, it does not always correlate to symptoms as a small gland may have significant inward growth and a large glands enlargement may be entirely peripheral.   

The ability to urinate involves the urinary bladder muscle actually becoming stronger as it works against increasing resistance from the prostate.  This delicate balance can be upset by any factor that decreases the bladder muscles ability to contract with sufficient force to open the prostate (such as medications, anesthesia, too much alcohol, ignoring the desire to urinate, etc.) or those factors that might cause the prostate to suddenly swell (ie acute prostatitis, sitting  for extended periods of time, biking, horseback riding, etc.). The typical symptoms that occur include diurnal frequency (daytime), nocturia (night-time frequency), urgency, hesitancy, slow stream and dribbling after voiding.  This complex of symptoms is termed “prostatism”.  If the obstruction to flow progressively worsens, the bladder eventually may not be able to empty completely.  This leads to the accumulation of “residual urine” which may predispose to urinary infections and  kidney damage from back pressure.

However, relatively asymptomatic men with BPH do NOT necessarily require therapy.  Treatment is indicated to relieve symptoms and prevent complications.  In many cases medications can be used.  Alpha - blockers (ie Hytrin, Cardura, Flomax, Uroxatral etc.) work by relaxing the bladder neck and urethra so the pressure generated by a bladder contraction has less resistance to work against.  Natural herbal products such a saw palmetto and pygeum often provide symptomatic relief but the exact mechanism of action has not yet been defined.  The prescription drugs Proscar and Avodart actually shrink the prostate.  They work best in the larger glands and improvement may not be noted for up to 6 months.   

In cases refractory to medication, interventional measures are indicated.  The “gold standard” for treatment is the time honored transurethral resection (TUR) of the prostate.  For huge glands, open surgery may be necessary.  In the past decade a number of other less invasive interventional therapies have been developed to reduce the obstructing prostate tissue utilizing various forms of energy.   These include laser prostatectomy, microwave (TUMP or transurethral microwave of the prostate), and radiofrequency (TUNA or transurethral needle ablation of the prostate).  TUMP is actually a minimally invasive, out-patient treatment that can be tried initially if the patient's gland size is appropriate.  

Here is an explanation of a TUR of the prostate gland.  The prostate gland can be thought of as being composed basically of three parts which from inside to out are: the prostatic portion of the urethra (urinary canal), the prostatic glandular tissue causing the obstruction (adenoma) and the compressed capsule of the prostate.  In a TUR, the prostatic urethra and adenoma are removed leaving only the capsule.  This surgery can be likened to coring out an apple from the inside leaving only the skin.  The prostate is resected into many tissue slivers which wash into the bladder and then are removed at the end of the operation by suction.  This leaves a raw bed, which, over a period of 6-8 weeks, regenerates a new urethra!  At the termination of the procedure, one can look from the far end of the prostate into the bladder without residual obstruction.  A catheter is left in for a few days to drain the bladder and to initiate the healing process.   Good luck!

Urology

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Arthur Goldstein, M.D.

Expertise

Problems or questions related to the field of urology; ie urinary stone disease, urinary cancers (kidney, bladder, prostate, testis, etc.), urinary infections, etc. I no longer answer questions related to erection problems or male sexual dysfunction.

Experience

I am retired from the active practice of urology. My 34 years was totally in the clinical field and involved the entire gamut of genitourinary problems, with special interest in endourology.

Organizations
American Medical Association, American Urological Association, American College of Surgeons

Education/Credentials
College degree - BS Medical degree - MD Master of Science - MS

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