Condition: Vergrote prostaat

In MTOPS, 3,047 men were randomized to placebo, doxazosin, finasteride, or both and followed a mean 4.5 years. Doxazosin cut overall clinical progression, defined as a rise of at least 4 points in the symptom score, acute retention, incontinence, renal insufficiency, or recurrent infection, by 39% against placebo, and improved symptoms significantly. Because these drugs relax smooth muscle, not shrink the gland, relief comes fast, within days to weeks, which is what makes them the usual first choice when symptoms are the problem and the gland is not very large. The tradeoff is that on their own they did not reduce acute retention or surgery in this trial. The older non-selective agent doxazosin can lower blood pressure and cause dizziness on standing; the prostate-selective drugs tamsulosin and silodosin cause less of that but more abnormal ejaculation.

The 5-alpha-reductase inhibitors block conversion of testosterone to dihydrotestosterone, the hormone that drives prostate growth, so they shrink an enlarged gland, not only relaxing muscle. In MTOPS finasteride reduced overall clinical progression by 34% against placebo and was, along with combination therapy, the arm that significantly reduced acute urinary retention and the need for invasive treatment. The PLESS study confirmed that the lower rate of retention and surgery persisted across six years. Because they act on gland size, they help most when the prostate is clearly large and take months, not days, to work, which is why they are often paired with an alpha-blocker for early relief. They also lower measured PSA by about half, a fact any clinician ordering a screening test needs to know.

MTOPS showed that combining doxazosin and finasteride reduced overall clinical progression by 66% against placebo, better than doxazosin (39%) or finasteride (34%) alone, because the two drugs work by different mechanisms: one relaxes muscle for fast relief, the other shrinks the gland to change the trajectory. The CombAT trial then tested dutasteride plus tamsulosin over four years in 4,844 men with prostates of at least 30 mL and higher risk of progression, and found combination therapy superior to either monotherapy for symptom improvement and better than tamsulosin at reducing acute urinary retention and BPH-related surgery. The benefit is concentrated in men with larger glands, and combination brings the side effects of both classes, so it suits men at higher risk of progression, not everyone with symptoms.

Saw palmetto is the most popular prostate supplement and was long recommended as an alternative to prescription drugs. Better trials revised that. The STEP trial randomized 225 men to saw palmetto or placebo for a year and found a difference in the symptom score of 0.04 points out of 35, with no difference in flow rate, prostate size, or residual volume. The CAMUS trial then took 369 men up to three times the standard 320 mg daily dose and still found no benefit over placebo. The 2023 Cochrane review concludes Serenoa repens does not improve urinary symptoms compared with placebo. The early positive reports came from smaller, lower-quality studies, which is where the reputation was built.

This trial randomized 556 men with moderate symptoms and no compelling reason to operate to either transurethral resection of the prostate or watchful waiting, meaning regular review with treatment held in reserve. Over three years surgery cut the rate of treatment failure to 8.2% against 17% for watchful waiting and produced larger improvements in symptoms and bladder function. But watchful waiting was far from a failure: most of those men remained stable, their symptom scores improved somewhat on their own, and about 24% eventually chose surgery within the three years. The reading is that for the bother-driven middle of the condition, the timing of treatment is a preference, and delaying it costs little for many men, which is what makes watchful waiting an active plan of monitoring, not neglect.

A review of drug-induced urinary retention lays out the mechanisms and the main offenders. Sympathomimetics, the class that includes over-the-counter decongestants such as pseudoephedrine and phenylephrine, tighten the smooth muscle at the bladder neck and can tip a man with an already narrowed outlet into acute retention. Anticholinergics, found in some older antihistamines, antispasmodics, and bladder and mood drugs, weaken the bladder muscle so it cannot push urine past the obstruction. Opioids do both. The risk is concentrated in men who already have bladder outlet obstruction from an enlarged prostate, which is exactly the reader of this page, so the practical step is to read cold-and-flu labels and tell a pharmacist about the prostate before starting one.

Between medication and full surgery sit several minimally invasive procedures. The prostatic urethral lift (UroLift) uses small implants to hold the enlarged lobes open; in a randomized sham-controlled trial of 206 men it improved symptoms and flow and preserved erectile and ejaculatory function, which sets it apart from resection. Water vapor thermal therapy (Rezum) injects steam to ablate obstructing tissue; a randomized trial of 197 men found it roughly halved symptom scores against a control procedure while preserving sexual function. Both are done under local or light anesthesia, often as day cases. They generally relieve symptoms somewhat less than transurethral resection but avoid much of its bleeding and its effect on ejaculation, and they suit smaller-to-moderate glands. How long the benefit lasts over many years is still being mapped.

A Cochrane review pooled 4 randomized, placebo-controlled trials of beta-sitosterol in 519 men lasting 4 to 26 weeks. It improved urinary symptom scores by a weighted mean of about 4.9 points and peak urine flow by about 3.9 mL per second, and reduced post-void residual volume, but did not reduce prostate size. The reviewers were explicit that long-term effectiveness, safety, and any ability to prevent BPH complications are unknown, because no trial ran long enough to test them. So there is a short-term signal sitting on old and brief studies, which is a narrower claim than these products are sold on.

A Cochrane review pooled 18 randomized trials in 1,562 men of Pygeum africanum, extracted from the bark of the African plum tree. Men taking it were more than twice as likely to report improvement, with roughly 19% fewer nocturia episodes and about a 23% increase in peak urine flow compared with placebo. The catch is the quality: the trials were small, mostly ran only weeks, used a range of non-standardized extracts and doses, and none measured prostate size or long-term complications. So there is a consistent short-term signal, but it sits on dated, methodologically limited studies, not the kind of large, rigorous trial that would settle it.

The American Urological Association symptom index, adopted worldwide as the International Prostate Symptom Score, asks seven questions about incomplete emptying, frequency, intermittency, urgency, weak stream, straining, and waking at night to urinate, each scored 0 to 5 for a total of 0 to 35. In its validation it was internally consistent, stable on retest, and tracked the man's own rating of how much the symptoms bothered him, which is why it is used to decide who can watch and wait and to measure whether a treatment is working. It deliberately measures symptom burden, not gland size, and the same score can come from overactive bladder or infection, so it guides the conversation, not settling the diagnosis on its own.