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Botox for the prostate?

May 12, 2008|Jill U. Adams | Special to The Times

Growing older has its perks -- heftier income, respect of one's peers -- and its drawbacks such as, for men, a steady enlargement of the prostate gland.

Soon, men with this problem may have a broader set of therapeutic options.

A 2003 study already has revolutionized the standard of care men get for this common condition. And new ideas about treating the symptoms of prostate gland enlargement now have doctors treating men with drugs better known for their effects on erectile dysfunction and wrinkled skin.

Viagra and Botox are just two of several drugs being studied for treating problems with urination and benign prostatic hyperplasia, the term for overgrown but noncancerous prostates that occur in most men as they age.

The oft-reported numbers are startling: At least 2 of 3 sixtysomething men have symptoms of an enlarged prostate gland, the organ that produces semen. Symptoms can be merely bothersome -- the need to urinate often, poor urine flow and incomplete emptying of the bladder. Or they can be serious enough to require treatment: bladder and kidney dysfunction; stones or infection in the bladder; and urinary retention -- inability to urinate at all.

For The Record
Los Angeles Times Wednesday, May 14, 2008 Home Edition Main News Part A Page 2 National Desk 2 inches; 77 words Type of Material: Correction
Enlarged prostate: An article in Monday's Health section about treatments for prostate enlargement gave inaccurate descriptions of two drugs used to treat the condition. The article said the drug dutasteride (Avodart) is an alpha blocker, used to relax muscles in the prostate and bladder. It also said tamsulosin (Flomax) is in a class of drugs called 5-alpha-reductase inhibitors, used to help shrink the prostate. In fact, Flomax is an alpha blocker, and Avodart is a 5-alpha-reductase inhibitor.
For The Record
Los Angeles Times Monday, May 19, 2008 Home Edition Health Part F Page 4 Features Desk 2 inches; 79 words Type of Material: Correction
Enlarged prostate: An article in the May 12 Health section about treatments for prostate enlargement gave inaccurate descriptions of two drugs used to treat the condition. The article said the drug dutasteride (Avodart) is an alpha blocker, used to relax muscles in the prostate and bladder. It also said tamsulosin (Flomax) is in a class of drugs called 5-alpha-reductase inhibitors, used to help shrink the prostate. In fact, Flomax is an alpha blocker, and Avodart is a 5-alpha-reductase inhibitor.

Drug use is fairly recent

Using drugs to treat enlarged prostates is fairly new. "Twenty years ago, we never used medications," says Dr. Steven Kaplan, a urologist at Weill Cornell Medical College in New York. Instead, when the condition became advanced, surgeons would cut away excess tissue.

Then a five-year study of 3,047 men published in the New England Journal of Medicine in 2003 caused a shift in medical practice. It found that a combination of two drugs helped relieve symptoms and halted the progression of the condition. "Now medications are the standard of care," says Kaplan, a coauthor of that research. Surgery is now reserved for men with very large prostates or intractable symptoms.

One of the drugs tested in that study is doxazosin (Cardura), which relaxes muscle in the prostate and bladder. This helps men maintain a steady urine stream and empty their bladders more completely.

The other drug, finasteride (Proscar), blocks the synthesis of a hormone thought to spur prostate growth and can reduce prostate size.

Study coauthor Dr. Claus Roehrborn, a urologist at the University of Texas Southwestern Medical Center in Dallas, says that interim results from a second long-term study of 4,800 men have corroborated the superiority of combination therapy, although with different drugs -- the alpha blocker dutasteride (Avodart), a drug in the same class as doxazosin, and tamsulosin (Flomax), which, like finasteride, is in a class of drugs called 5-alpha-reductase inhibitors.

Doctors agree that alpha blockers are primarily responsible for ameliorating symptoms. But preventing the big risks, urinary retention and surgery, requires the combination.

And new approaches are under study. "What used to be a two-horse race has just exploded," Kaplan says.

Prostate health is by definition a man's issue. Yet one of the most promising new treatment drugs is borrowed from women's troubles with urinary urgency, termed "overactive bladder" by doctors. Doctors avoided the drugs in the past, fearing that supressing bladder activity would increase the risk of urinary retention in men. That fear has not been borne out in several studies, including a 2006 trial of more than 800 men published in the Journal of the American Medical Assn. In it, tolterodine (Detrol LA), used to treat urinary incontinence, decreased urinary symptoms associated with an enlarged prostate. Side effects were minimal, and rates of urinary retention were low and unaffected by drug treatment.

No study has shown that drugs for overactive bladder are better than combination therapy, but they may be helpful in men whose symptoms are due to a bladder issue rather than the effect of the prostate leaning on the bladder, researchers say.

Another new drug development comes from anecdotal reports that men taking drugs for erectile dysfunction were urinating better. In response, drug companies, including Pfizer (which markets Viagra) and GlaxoSmithKline (which markets Levitra) and Eli Lilly & Co. (which markets Cialis) are studying their erectile dysfunction drugs in men with benign prostatic hyperplasia.

One of these studies, of vardenafil (GlaxoSmithKline's Levitra), was published earlier this year in European Urology. In it, 222 German men were given either vardenafil or a placebo for eight weeks. Those receiving the drug reported improved urination equivalent to that obtained with Flomax, as well as improved erectile function and quality of life.

And Roehrborn this month will present results from an Eli Lilly-funded clinical trial at an American Urologist Assn. meeting showing that tadalafil (Cialis) was as effective or better than the alpha blocker drugs in improving enlarged prostate symptoms.

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