Enlarged Prostate / BPH
We offer the full range of approved treatment options for Enlarged Prostate / BPH including personalized drug therapy, Rezum®, UroLift®, and TRUP.
Enlarged Prostate or BPH (Benign Prostatic Hyperplasia) is the most common reason for urinary symptoms in men. Some growth of the prostate occurs in nearly all men as they grow older. The prostate surrounds the urethra, which is the tube that carries urine out from the bladder. As the prostate grows, it can obstruct the flow of urine and lead to urinary symptoms.
While we commonly use the term “enlarged prostate,” prostate size alone does not determine the degree of obstruction to urine flow. Some men with smaller prostates may have a prostate structure which leads to obstruction.
Typical symptoms of urinary obstruction from BPH/Enlarged Prostate include:
- Weak or reduced urinary flow
- Difficulty starting your urinary flow
- Waking from sleep to urinate
- Incomplete Emptying of Bladder
- Need to Urinate Frequently
- Urgency to get to the bathroom quickly
Some of these symptoms are fairly specific to BPH, but others may be also be due to other causes. Our team can help work-up your urinary symptoms, determine what is causing your symptoms. This questionnaire can be helpful in identifying the cause and extent of your urinary problems [link to AUA-SI].
Health and Quality of Life
Urinary symptoms from BPH can be detrimental to your quality of life and, in some cases, your health. Waking up multiple times per night can lead to fatigue, sexual dysfunction, and mood and hormonal problems. The need to urinate frequently or urgently can lead to disturbance of work or family life and can sometimes cause patients to avoid social situations. With mild or moderate BPH symptoms, treatment is aimed at improving quality of life and preventing the situation form getting worse.
In severe cases, BPH can become dangerous to your overall health. Inability to empty the bladder can increase the risk of urinary tract infections and prostatitis (prostate inflammation or infection). In severe cases, BPH and the resulting retention of urine can lead to kidney damage.
BPH/Enlarged prostate can influence PSA levels, a blood test used to screen for prostate cancer. However, BPH does not actually increase your risk of having or developing prostate cancer. Prostate cancer and BPH typically occur in different parts of the prostate.
Treatment Options for BPH/Enlarged Prostate
At Metrowest Urology we start with a thorough investigation of the patient’s prostate and urinary health and consider each individual’s medical problems and quality of life concerns before recommending treatment. Some men may achieve good results with behavioral therapy and monitoring alone. Our physicians have a background in pharmacology/drug development and can help design medication treatment protocols tailored to an individual’s needs.
While medications are effective for many patients, urinary symptoms due to BPH/Enlarged Prostate are a mechanical problem that is sometimes best treated with a procedure to relieve the obstruction. A procedure may be the best treatment for a patient who has severe symptoms not controlled by medications or adverse reactions to long-term medical therapy. Our surgeons are certified and experienced with the complete range of minimally invasive and surgical procedures including Rezum®, UroLift®, GreenLight Laser, TRUP, TUMT, and open prostatectomy.
Behavioral Therapy and Supplements
For men with mild symptoms due to an enlarged prostate, small changes in behavior can help minimize urinary symptoms. Avoiding fluids before bed can help minimize the need to get up at night to urinate. Effective treatment of sleep apnea or swelling on the legs may also help minimize nighttime urinary symptoms. Double voiding (urinating twice in order to empty better) can be helpful during the day and night. Men who only have mild symptoms managed with behavioral therapy should still check in with a urologist every year or two for an examination and check of the amount of urine retained in the bladder after urinating.
Since urinary symptoms related to the prostate are very common, these conditions have become a target of the supplement industry. Several supplements claim that they can improve urinary symptoms or general prostate health. Nonetheless, there is no evidence that these supplements are effective. In fact, several supplement formulations have been shown to be ineffective in clinical trials. Many more, however, have not been formally studied. In our experience, some men may achieve a very mild benefit from saw palmetto but claims of efficacy from other components is dubious.
In general, three classes of medications are used to treat enlarged prostate/BPH:
- Alpha – Blockers – This class of medications include Flomax (tamsulosin), Uroxatral (alfuzosin), and Rapaflo (silodosin) among several older drugs. These medications relax the normal muscles that maintain tone inside the prostate in order to counteract the obstruction. In general, they are effective for the majority of patients with obstruction. However, these medications can lead to some lightheadedness/fatigue or a decrease or complete loss of ejaculate volume (retrograde ejaculation).
- Hormonal Drugs (5 alpha Reductase Inhibitors) – This class of drug includes finasteride and dutasteride. They actually help shrink the prostate by reducing the influence of androgens (male hormones). While effective alone and in combination with alpha-blockers, these medications can have hormonal side effects include loss of libido, low energy, erectile dysfunction and other forms of sexual dysfunction. Recent research has also shown that these drugs may have an insidious effect on metabolism leading to an increase in blood sugars. These drugs can be useful in the short term, but men with metabolic problems may with to avoid in the long term.
- Daily Tadalafil – Daily use of tadalafil (also known as Cialis) can be very helpful for urinary symptoms and may also have positive sexual benefits. While we think of tadalafil as a medication that increased blood flow to the penis, it also appears to increase blood flow to the prostate, bladder, and pelvic floor muscles. Men on this medication often report an increased strength of their urinary stream with decreased frequency and urgency. In a minority of men, tadalafil can cause several bothersome side effects including gastric reflux, backache, or headache. People who take nitrates for angina can not take tadalafil. Some insurance plans may not cover brand name Cialis as a daily pill, but essentially identical generic tablets can be purchased at relatively low cost through compounding pharmacies.
In some cases, BPH can co-exist with other urinary problems such as nocturnal polyuria (making too much urine at night) or overactive bladder. Therefore, your provider may use combinations of other medications to help alleviate urinary symptoms.
Minimally Invasive Treatment
Minimally invasive, office-based procedures have advanced in recent years and can now offer similar efficacy to a full surgical procedure without the need for general anesthesia, hospital stays, or lengthy recovery. These procedures can all be performed comfortably in the office using a combination of local anesthesia, low dose oral pain medications, or use of Nitrous Oxide.
We offer all major minimally invasive treatments for BPH/Enlarged Prostate. There is no “one size fits all” procedure for BPH, and an individual’s specific prostate shape, size, and symptoms can determine which procedure is best for him. Patients with very large prostate glands, bladder stones, or very severe symptoms may not be good candidates for minimally invasive procedures.
Rezum® is a cutting-edge technique which uses steam to target obstructing prostate tissue, which is later destroyed without damage to surrounding structures. Rezum® has largely replaced a similar, older procedure called TUNA, which used a less precise technology for destroying prostate tissue. Rezum® has a very low rate of sexual side effects and therefore may be a good choice for patients who wish to maintain fertility or normal ejaculation. In our experience, certain prostate shapes/configurations respond particularly well to treatment with Rezum®.
Urolift® is unique among BPH treatments in that it does not involve destroying prostate tissue. Instead the obstructing prostate tissue is pinned back and out of the way of urine flow. Since there is no energy source and no destruction of tissue, the typical recovery from Urolift® is quicker and easier compared to other procedures. Published data indicate that improvements in urinary symptoms remain for at least 5 years but may last for much longer.
Transurethral Microwave Therapy with the Prolieve system is a simple and low risk procedure with generally excellent recovery. While TUMT is effective for a large majority of patients the benefit typically lasts for about 2 years. After that, patients are candidates for repeat TUMT, or any other treatment option.
Surgical treatment in the operating room remain the gold standard for treatment of prostate obstruction. It may be particularly appropriate for patients with very large prostate, bladder stones, or very severe symptoms. The goal of surgical therapy is generally to remove all obstructing prostate tissue in order to achieve relief from obstruction for the long term (10 years or longer). Since there is significant resection of tissue, the procedure occurs under anesthesia and involves use of a catheter to control bleeding. Recovery from this procedure is generally longer and more significant compared to minimally invasive therapies.
Several methods may be used in the OR to remove tissue without external cuts and working through the patient’s urethra. This may include use of a cutting loop (TURP) or flat surface (“Button TURP”). The GreenLight Laser is particularly useful at removing tissue while also controlling bleeding. As such, the GreenLight laser can be used for men who have cardiovascular issues that prevent them from stopping blood thinner medications, such as Asprin, Plavix, or Coumadin.
In extreme cases, the prostate may be large enough that is not possible to effectively remove the obstruction by working through the urethra. In these cases an external incision must be made in the lower abdomen (open prostatectomy) or the obstructing prostate tissue can be removed using robotic surgery.