Enlarged prostate plus overactive bladder

[Twittering]

Hello Experts!

I am a 69-year old who has had a moderately enlarged prostate (benign prostatic hyperplasia) and an overactive bladder for at least 10 years. For a good number of those I have been getting up an average of 3 to 4 times to pee. As you can imagine, this leaves me tired and not up to my best in the daytime, when I also have the usual symptoms of urgency, frequency etc. I am taking Tamsulosin and Finasteride. I have tried other antimuscarinic drugs for a good length of time but they have effected no improvement, nor have pelvic floor exercises and bladder training. (With the latter, it is very difficult to hold on for long without leaking.) Voiding is pretty good but takes time.

In addition I usually have heartburn at night, which has been diagnosed by a gastroenterologist as not particularly due to acid reflux but just age-related degeneration of the digestive system.

I have been advised to cut down on caffeine. I must admit I find it difficult to do without ‘proper’ coffee entirely, though I have a maximum of one or two cups a day. I was subsequently told that even decaffeinated tea and coffee contain tannin, which is also a bladder irritant, so I generally have only Redbush tea, which has no caffeine and only half the tannin of normal tea. Alcohol intake is negligible Even so, a GP said I should try drinking nothing but water for two weeks, which I have not done yet.

My questions are:

1. If cutting down on caffeine and tannin was going to help, should it not have done so by now?

2. I am sceptical but, if drinking only water calms my bladder down, does that mean I would have to drink only water for the rest of my life? I think I would rather put up with the condition.

3. Should I try taking Tamsulosin and Finasteride in the evening, despite the leaflet saying that Tamsulosin should be taken after the first meal of the day?

4. As I also have an overactive bladder, how likely is an operation on the prostate (TURP etc) to improve matters? In view of the possible short or long term side effects (incontinence etc), is it worth putting myself through it?

5. Should I ask my doctor for a referral to a urologist? (So far, I have only seen GP’s and attended a continence clinic.)

Any advice will be gratefully received. Thanks

[Dr Jon Rees]

Hi

great questions!

to answer them:

1. yes, I would have expected so.

2. I don't think having to drink nothing but water for the rest of your life is a solution to your symptoms.

3. unlikely to make much difference, but there is no harm in trying if you want to.

4. TURP or other surgery is definitely an option, but you are right that the surgery is particularly good for the 'voiding' symptoms of prostate enlargement eg slow flow, hesitancy, intermittency, dribble etc and less good sometimes for the 'storage' symptoms ie urgenr desire to urinate, going frequently day and night.

5. yes, you should definitely ask for specialist assessment - I would want to carry out a flow test to see if there is ongoing evidence of voiding problems despite the tablets you are taking. Your symptoms are far from sorted out despite taking 2 medications, and you need further advice. It should be possible to get far better symptom control for you and still be able to have the odd proper coffee!

[Twittering]

Thanks. Very useful answers.

[Mr Benjamin Challacombe]

I would agree with what Jon has said but add that with your mixed picture of both bladder storage and bladder emptying symptoms that the next step might be formal bladder pressure studies- urodynamics
It sounds like you have tried most combinations and therefore before any intervention like TURP etc we need to know exactly what is going on.
Ben

[Twittering]

Thank you for your comments. I have had two or three flow tests. The scans indicated that my voiding was pretty good as I always try to take the time to empty my bladder as much as possible. Do you still think I could have a problem in this respect? Would urodynamics still be a good idea? What might it reveal and what would the possible remedies be?

[Dr Jon Rees]

yes, if flow tests have shown reasonable flow and good emptying, you really want to work out if you have evidence on urodynamics of an overactive bladder which is just failing to respond to anticholinergic drugs - if that were the case, it might be worth considering a trial of a new medication called mirabegron which is now used second line for this after anti-cholinergic failure.