These are tablets that relax the muscles in the prostate and around the opening of the bladder, making it easier to urinate.They don’t cure an enlarged prostate but they can help to relieve symptoms.

Alpha-blockers are usually the first type of medicine you will be offered, unless your prostate is very large. Symptoms may start to improve within a few hours or days, but you may need to take alpha-blockers for a few weeks before they work fully.

Around 3 in every 5 men who take alpha-blockers find their symptoms improve within the first month of treatment. If your symptoms haven’t improved after about four to six weeks, your doctor may suggest trying a higher dose or a different treatment. For most men, alpha-blockers continue to work for several years.

There are several alpha-blocker medicines available. They all work in the same way and are equally effective at managing symptoms of an enlarged prostate. The most common alpha-blockers are called:

• tamsulosin (Flomaxtra^®, Diffundox^®, Flomax Relief^®, Pinexel^®, Stronazon^®)
• alfuzosin (Xatral^®, Besavar^®)
• doxazosin (Cardura^®, Doxadura^®)
• terazosin (Hytrin^®).

Like any medicine, alpha-blockers can cause side effects. These affect each man differently, and you may not get all of the possible side effects. Side effects usually stop if you stop taking the medicine. Possible side effects include:

• feeling dizzy or sick (nausea) or having a headache when you stand up – this usually stops after the first few doses
• tiredness or fatigue
• a blocked nose
• problems getting or keeping an erection (erectile dysfunction) – this affects around 3 in every 100 men (3 per cent)
• dry orgasm (where you release little or no semen when you orgasm) – this affects around 2 in every 100 men (2 per cent).

Read the information leaflet that comes with your medicine for more information on side effects, or speak to your doctor, specialist nurse or pharmacist. If you are having any eye surgery, make sure you tell your eye surgeon that you are taking alpha-blockers. This is because some alpha-blockers can cause problems during eye surgery.

These medicines slowly shrink the prostate so that it stops pressing on the urethra, making it easier to urinate. They can shrink the prostate by around a quarter after 6 to 12 months of treatment. They may shrink the prostate even more if taken for longer.

5-alpha-reductase inhibitors usually take at least six months to work fully, but they are effective at improving symptoms in the long term. Studies show that men's symptoms may continue to improve up to four years after starting treatment. 5-alpha-reductase inhibitors also help to prevent acute urine retention and the need for surgery.

You'll usually be offered 5-alpha-reductase inhibitors if your prostate is very large. This is because they work particularly well in men who have a larger prostate. You may also have to take them in combination with an alpha-blocker.

There are two 5-alpha-reductase inhibitor medicines available:

• finasteride (generic finasteride or Proscar®), taken as a tablet once a day
• dutasteride (Avodart®), taken as a capsule once a day.

5-alpha-reductase inhibitors may cause side effects. These are most common during the first year of treatment. They usually stop if you stop taking the medicine. Possible side effects include:

• problems getting or keeping an erection – this affects around 7 in every 100 men (7 per cent)
• less desire for sex (low libido) – this affects around 5 in every 100 men (5 per cent)
• breast swelling or tenderness – this affects around 2 in every 100 men (2 per cent)
• changes in your ejaculation, such as dry orgasms or retrograde ejaculation (where semen doesn’t come out straight away when your orgasm, but leaves the body when you next urinate) – these changes affect around 2 in every 100 men (2 per cent).

Read the information leaflet that comes with your medicine for more information on side effects, or speak to your doctor, specialist nurse or pharmacist.

If you're taking 5-alpha-reductase inhibitors, you should use a condom during sex if there is a chance your partner is pregnant or could become pregnant. Pregnant women and children should avoid touching broken tablets or capsules. Ask your doctor or nurse for more information.

5-alpha-reductase inhibitors and your PSA level

5-alpha-reductase inhibitors reduce the amount of PSA in your blood. This means your doctor or nurse will need to change the way they look at any PSA tests you have, as your PSA levels will be lower than normal. If you have a PSA test, always tell your doctor or nurse if you are taking 5-alpha-reductase inhibitors. If your PSA level rises, your doctor should offer you further tests to find out why.

Your doctor may suggest other medicines to help control your symptoms, including the following.

• Anticholinergics, such as oxybutynin, tolterodine (Detrusitol XL^®) and solifenacin (Vesicare^®). These can help improve symptoms such as a sudden urge to urinate, needing to urinate more often than usual, and leaking before you reach the toilet. Anticholinergics can have similar side effects to alpha-blockers. They can also cause other side effects, such as dry eyes, a dry mouth and constipation.
• Phosphodiesterase type 5 (PDE5) inhibitor. You might be offered a PDE5 tablet called tadalafil (Cialis^®). Tadalafil relaxes the muscles in the prostate and around the opening of the bladder, making it easier to urinate. Symptoms may start to improve within the first week. Tadalafil is more commonly used to treat erection problems and is usually only given to men with an enlarged prostate as part of a clinical trial. It can cause side effects including headaches, indigestion, back pain, and itchiness or swelling in your nose (rhinitis). These side effects are usually mild and don’t last long.
• Mirabegron (Betmiga^®). If anticholinergics aren’t working, or you can’t take anticholinergics, your doctor may recommend trying mirabegron tablets. Mirabegron is a new type of drug called a beta-3-adrenoceptor agonist. It can help if you need to urinate more often than usual or get sudden urges to urinate. Possible side effects include high blood pressure, urine infections and headaches.
• Desmopressin. If you urinate a lot during the night, your doctor may recommend taking a desmopressin tablet before you go to bed. This causes the kidneys to produce less urine for six to eight hours. You will have regular blood tests to monitor your kidney function. Desmopressin isn’t usually an option if you’re over 65 or have heart failure.
• Loop diuretic. This makes you urinate a lot before you go to bed, making it less likely that you’ll need to get up during the night. You take it as a capsule in the late afternoon.

Some men find that taking more than one type of medicine works better than taking a single medicine on its own. This is known as combination treatment. You might be given separate tablets, or you might be given a single tablet containing both medicines to take each day.

Alpha-blocker plus 5-alpha-reductase inhibitor

You may be offered an alpha-blocker together with a 5-alpha-reductase inhibitor if:

• your symptoms affect your day-to-day life, and
• you have a very large prostate or a PSA level of more than 1.4 ng/ml.

Alpha-blockers and 5-alpha-reductase inhibitors can both cause side effects, so you might get side effects from both medicines. Some side effects, such as less desire for sex, changes in your ejaculation and erection problems, are more common in men taking both medicines than in men who take either medicine on its own.

Alpha-blockers can start to work within a few hours or days, while 5-alpha-reductase inhibitors usually take at least six months to work fully. This means that men on combination treatment may be able to stop taking the alpha-blocker after around nine months, without making their treatment less effective.

Alpha-blocker plus anticholinergic

You may be offered an alpha-blocker together with an anticholinergic, if treatment with either medicine alone isn’t working. Alpha-blockers and anticholinergics can both cause side effects, and these may be worse if you’re taking both medicines at the same time. The most common side effects in men taking both medicines include a dry mouth, constipation and indigestion.

Some men like to use herbal remedies, such as saw palmetto or red stinkwood (African plum). But studies suggest they’re unlikely to improve symptoms of an enlarged prostate. We need more research before herbal remedies can be recommended as a treatment.

Not all herbal remedies in the UK are licensed, and the quality varies a lot. Be very careful when buying herbal remedies over the internet. Many are made outside the UK and may not be high-quality. Many companies make claims that aren’t based on proper research. There may be no real evidence that their products work, and some may even be harmful. Remember that even if a product is ‘natural’, this doesn’t mean it is safe.

At the moment, there’s no evidence that acupuncture or homeopathy can help manage symptoms of an enlarged prostate.

It’s important to tell your doctor about any complementary therapies you are using. Some may interfere with your enlarged prostate treatment or with other medicines you may be taking. Some herbal remedies may also affect your PSA level, making the PSA test unreliable. For more information about using herbal remedies safely, visit the MHRA website.

This is an operation to remove the parts of the prostate that have grown too large and are pressing on the urethra. It is the most common type of surgery for an enlarged prostate.

During the operation, the surgeon passes a thin tube up your penis into your urethra. They then pass an electrically-heated wire loop through the tube and use it to remove small pieces of prostate tissue.

This is similar to TURP but uses a high-powered laser to remove the parts of the prostate that are blocking the urethra. Studies suggest that HoLEP is as effective as TURP at improving symptoms of an enlarged prostate, with similar side effects in the short term. HoLEP may be particularly useful in men with a very large prostate. You may also be less likely to need further surgery after HoLEP than after a TURP.

HoLEP uses specialist equipment and the surgeon needs to have had special training. This is why HoLEP is usually only available at specialist centres.

This is similar to TURP, but parts of the prostate are destroyed with heat rather than being cut away. An electric current is passed into a small roller ball (like a computer mouse ball) or a mushroom-shaped electrode. This heats up and destroys the prostate tissue blocking the urethra.

Studies show that TUVP is as effective as TURP at improving symptoms. But some men may need more treatment in the future.

This uses a high-energy laser to heat up and destroy the prostate tissue that is blocking the urethra. You might also hear it called photo-selective vaporisation of the prostate (PVP), GreenLight XPS™, or laser prostatectomy.

GreenLight™ laser surgery may be as effective as TURP, at least in the first two years after surgery. But we don’t know how long it works for or about any long-term side effects.

This is a new type of surgery for an enlarged prostate. It involves putting small implants into the prostate. The implants pull the excess prostate tissue away from the urethra so that urine can flow more easily. This can help to improve symptoms without actually removing any tissue from the prostate.

It isn't available in all hospitals because the surgeon needs to have had special training. We don’t yet know how long it works for, or the possible side effects in the long term (longer than five years).

You may also hear this called a transurethral incision of the prostate (TUIP). A bladder neck incision may be suitable if your prostate itself isn't very large or if your symptoms are caused by other problems, such as a narrow opening from your bladder.

It is a simpler operation than a TURP and has a shorter stay in hospital. The surgeon passes a thin tube up your penis into the urethra. They then pass an instrument up the tube and use it to make a few small cuts (usually one or two) in the opening of the bladder, where the bladder meets the prostate. This makes the opening of the bladder wider so that urine can flow out more easily.

Studies suggest that a bladder neck incision is as effective as a TURP at improving symptoms in men with a small prostate. You may sometimes need both a bladder neck incision and a TURP, depending on what is causing your urinary problems.

This is an operation to remove the inner part of the prostate through a cut in the abdomen (stomach area). It isn’t used very often. But it may be an option if your prostate is very large, or if you have other health problems such as large bladder stones. It involves a longer stay in hospital than other types of surgery for an enlarged prostate.

There are some other less common types of surgery, such as:

• transurethral vapour resection of the prostate (TUVRP)
• prostate artery embolisation
• transurethral water vapour therapy (Rezūm^®).

These treatments aren’t available in many UK hospitals. They’re usually only available as part of a clinical trial or through private healthcare.

As with most treatments, there is a risk of side effects after surgery to treat an enlarged prostate. Possible side effects include:

• needing to urinate more often or urgently
• leaking urine when you cough, sneeze, laugh or exercise
• blood in your urine
• urine infection
• a weak flow when you urinate
• retrograde ejaculation
• problems getting or keeping an erection.

Your chances of getting each of these side effects will depend on many things, including the type of surgery you choose. Speak to your doctor or nurse for more information.

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