The prostate is a tiny gland situated between the bladder and the penis. But as men get older, the gland grows larger, putting pressure on the urethra and bladder and causing urinary problems. An enlarged prostate is medically called benign prostatic hyperplasia (or BPH), a condition that’s quite common in older men. In the U.S. around 50 percent of men 51-60 years old have BPH while up to 90 percent of men over age 80 are affected by the condition.
The common symptoms of an enlarged prostate are:
- Inability to delay urination.
- Urge to urinate more than 8 times a day.
- Frequently waking up at night to pass urine.
- Dribbling after urinating.
- Urinary incontinence (urinating accidentally).
- Inability to completely empty the bladder (urinary retention).
- Having intermittent or weak urine stream.
- Straining to pass urine or difficulty starting urination.
So what are the options for treating BPH?
As urologists, the first thing we do when a patient has symptoms is to rule out other possible problems. We talk with our patients to learn the nature and severity of their symptoms, conduct exams, do ultrasound and relevant tests. Once it’s confirmed that it is BPH, we begin treatment starting with the least invasive procedures. Treatment options for BPH include medication, minimally invasive procedures and surgery, although various lifestyle changes also can improve or prevent symptoms.
The urologist may recommend medication to help control prostatic growth and reduce symptoms. For instance, alpha blockers such as alfuzosin (Uroxatral), silodosin (Rapaflo), doxazosin (Cardura), tamsulosin (Flomax) and terazosin (Hytrin) may be used to relax prostate muscles and make it easier to urinate. They quickly increase urine flow and reduce the need to urinate frequently. Another type of medication that may be prescribed is 5-alpha-reductase inhibitors, such as finasteride (Proscar) and dutasteride (Avodart), which limit the growth of the prostate by blocking hormones that promote growth of the gland. It generally takes 3-6 months for 5-alpha reductase inhibitors to relieve symptoms.
Phosphodiesterase-5 (PDE5) inhibitors such as Sildenafil, (Viagra), Tadalfil (Cialis) and Vardenafil (Levitra) may be given to help relax urinary tract muscles and relieve BPH symptoms. However, in some cases, particularly when either a 5-alpha reductase inhibitor or an alpha blocker isn’t effective on its own, urologists may give a combination therapy. This typically involves a combination of a 5-alpha reductase inhibitor and an alpha blocker and usually results in greater symptom relief.
2. Minimally invasive procedures
When medications fail to relieve BPH symptoms, the next step in treatment usually involves minimally invasive interventions. During the procedure, a urologist inserts an instrument into the rectum or urethra to either widen the urethra or destroy excess prostate tissue. For instance, TUMT (Transurethral Microwave Thermotherapy) uses microwaves to heat and destroy excess prostate tissue. TUMT does not cure BPH but makes it easier to pass urine, cuts down urinary frequency and reduces weak flow. Another treatment, TUNA (Transurethral Needle Ablation), uses high-frequency radio waves that are delivered via twin needles to burn a specific area of the prostate. TUNA is an outpatient procedure that relieves BPH symptoms and improves urine flow.
A third minimally invasive option for BPH is water-induced thermotherapy. During the treatment, hot water delivered through a catheter and into a treatment balloon located at the center of the prostate is used to heat up a definite area of the prostate and destroy problematic tissue. Once destroyed, the excess tissue is either reabsorbed in the body or excreted through urine. Another minimally invasive treatment option is the Urolift procedure, which involves inserting small implants into the prostate to retract, hold and lift the enlarged prostate tissue, opening up the passage for urine and relieving bladder blockage. While the Urolift procedure does not involve heating, cutting or removing the excess prostate tissue, it is effective in restoring normal flow of urine and relieving symptoms, and patients usually return home the same day without a catheter.
A revolutionary minimally invasive procedure for treating BPH is the Rezum system. During the treatment, sterile water vapor is injected into the prostate to help destroy overgrown tissue. It takes roughly three months for the body’s healing mechanisms to remove dead prostate cells and shrink the prostate, opening the passage for urine to flow. The Rezum procedure improves urine flow and relieves symptoms without the adverse effect of erectile dysfunction. It’s an ideal option for men who are medically unfit for the other procedures or for those already catheterized.
For prostates that have grown larger than 100 grams, a procedure called aquablation is a good option. It uses a high velocity saline jet to remove the overgrown prostate tissue. After the treatment is planned, the procedure is robotically driven, so its duration and side effects do not depend on prostate size. It does not use heat and postoperative bleeding is prevented by inserting a large catheter and applying a bladder washout (irrigation). The results achieved through aquablation are similar to TURP, except it comes with less dysuria and minimal irritation symptoms because no heat is used.
3. Surgical procedures for treating BPH
If both medication and minimally invasive procedures fail to improve BPH symptoms sufficiently, the urologist may recommend surgery. Surgical interventions also may be necessary if complications develop or symptoms become severe. The most common type of invasive surgery for BPH is TURP (Transurethral Resection of Prostate). In fact, it’s the first surgical option for treating BPH and involves the removal of excess prostate tissue by inserting a resectoscope through the urethra and into the prostate. Or the urologist can opt for TUIP (Transurethral Incision of Prostate) that involves making incisions in the bladder’s neck and into the prostate. The operation is done to widen the urethra and boost urine flow.
In other cases, the urologist may choose to perform laser surgery. This surgical procedure involves inserting a scope into the urethra and using the scope to deliver laser to the prostate tissue. The laser treats enlarged prostate through either enucleation (cutting) or ablation (melting). Both the GreenLight Laser PVP and Holmium laser ablation of prostate (HoLAP) procedures remove the excess prostate tissue by photoselective vaporization while holmium laser enucleation of prostate (HoLEP) uses two instruments, a laser for cutting and removing excess tissue and a morcellator for slicing extra tissue into tiny fragments for removal.
In complicated cases of BPH, such as men with much enlarged prostates or those with bladder damage, urologists may opt for open surgery. During an open simple prostatectomy, the urologist makes an incision just below the navel or numerous small incisions in the abdominal area via laparoscopy. The surgeon then removes the portion of the prostate that’s blocking urine flow.
At Advanced Urology Institute, our choice of treatment usually comes down to patient preferences and their ability to cope with BPH symptoms. We often prefer the least invasive options and give medication in many cases, but other treatment options are considered for patients who aren’t responding well to drugs or who can’t tolerate the adverse effects. As an alternative to TURP and open surgery, we prefer to treat BPH that’s characterized by acute urinary retention, high post-residual volume, recurrent urinary tract infections or bladder stones through the GreenLight Laser PVP or the newer heat treatments like TUNA and microwave. For more information on treatment options for BPH, visit the “Advanced Urology Institute” site.