Let's talk about the... Let's talk first about the class of drugs that shrink the prostate.
Okay, so... You know, I'm going to take a step back because there was nothing to treat
BPH with until some doctors developed the TURP surgery. 1930s they started carving...
T-U-R-P, right?
Transurethral Resection of the Prostate, and they started carving the prostate with kind
of rudimentary techniques that have been refined over the years. So from the 1930s to the late
1980s that was it. If you had BPH symptoms that needed some therapy, you got a TURP.
So at most dinner tables, people get to talk about politics or other things. At my house,
we talked about TURPs because my daddy did a ton of TURP's. And they still do TURP's
today.
It's different though, and in the 60's and 70's, since this was the only BPH therapy,
this was the number one surgery of any kind performed in America. Like, more than hernias
or cataracts, eartubes, or anything. So, I just put that as a backdrop. In my residency
training which ended in 1991, that's all we did. And then right towards the end of residency,
we're hearing about these drugs that were being evaluated and they came along, and they
came in the order of first, the alpha blockers, and then the 5 alpha-reductase drugs, the
shrinkers. So let's just take them in that order because this is often the order in which
they're prescribed. We have alpha blockers, which "alpha" refers to a receptor, which
is what leads to a muscle contraction or in the case of a blocker, a failure to contract.
So these are drugs that name names I guess, you know, they started with Prazosin (we don't
use that anymore), they went on to Hytrin and Cardura (don't use those much anymore
because they're less specific, they're more likely to be associated with high blood pressure,
they're used as blood pressure meds). And then, along came sort of the mainstays, even
today, Flomax which is Tamsulosin generically, Uroxatral which is Alfuzosin, and another
one that has yet to be generic is the Rapaflow (Silodosin), and these all have the advantage
over the earlier ones of being a little more specific. They target the specific type of
alpha receptors in the prostate.
So this is that class of drugs you were talking about that relax the prostate. They relax
the prostate.
so there's muscular tissue in the prostate and there's glandular tissue. So the muscular
tissue responds to the alpha blockers by relaxing, to some degree, correct. And the glandular
tissues are unaffected by these drugs. So, and I should point out the fact that prostates
come in various combos—mostly muscular, mostly glandular, and a good old mix in the
middle. It typically is that the smaller prostates are the muscular prostates and the larger
prostates are the glandular prostates. So we should talk about the shrinkers next. So,
anyway, these drugs are still in use and as you said, people start them...
The relaxers?
The relaxers. They start them with some degree of enthusiasm. Here's a fix. And then oftentimes
are, you know, I guess discouraged because of side effects, because of lack of real change,
and sometimes just the hassle or the cost of these drugs, even if they're generic they
are very costly.
But for some guys, these relaxers work, and don't they work pretty quickly?
That's one advantage. If they're going to work they're going to work within a couple
of weeks. So, it's a quick fix. But, on that 35 point scale, they work to the tune of about
3 or 4 points. So how that, how a man perceives that as impactful is a little bit beyond me,
but patients will come in and say, you know, I was up 4 times a night, now it's 3, I'm
happy. You know? And we often wonder if that's really enough to get happy about. But over
time, you know, up to 70% of these guys, in a year, will stop their drugs.
So, these are still expensive. Some are generic even though it's still costly. We talked about
side effects of these relaxers, of the alpha blockers. So what are some of the side effects
relaxers that you don't like?
So, you know, dizziness really concerns me in elderly patients, we can sometimes reduce
the dizziness by combining these drugs with food, but dizziness could be literally a lethal
side effect in an older person who then falls, breaks his hip, and gets pneumonia and dies.
I mean, we see these things. Or, just the fact that in an older person these drugs don't
quite get the job done and they're rushing to the bathroom, there's another opportunity
for a trip and a fall. Things like nasal congestion. I skipped right past the eyes, but there's
something called Floppy Iris Syndrome which impacts future cataract surgery. And then
notoriously these drugs impact ejaculation. It impedes, they impede the amount of semen
that is expelled at the time of ejaculation.
So that's where they came up with the world retrograde ejaculation?
Right, in some cases it's retrograde and in some cases, it's really anejaculation, nothing
happens at all. The whole system is sort of paralyzed, and I think men don't like that.
That was a polite way of saying it. I wouldn't like that, especially if it's going the wrong
direction.
Yeah.
Anyway.
There have been even some greater concerns just recently on the rise in things like strokes
that may be associated. So I think, I think that not only do these drugs not do much in
terms of the symptom profile—and they have significant side effects—they also don't
stop the progress of BPH. They don't change the natural history, they just sort of pull
a patient back a little bit on the timeline and then, you know, they continue forward.
And I think patients figure this out, as I said because the symptoms, recovery of symptoms,
is not compelling for many of them.