Around the time of a man’s 25th birthday, his prostate begins to grow. This natural enlargement is called benign prostatic hyperplasia (BPH). It is the most common cause of prostate enlargement. Indeed, if a man lives long enough, he will almost certainly experience some degree of BPH—a benign condition that doesn’t lead to cancer, although the two problems can coexist.
No one knows exactly why BPH occurs. One popular theory suggests that the prostate begins to grow because of shifts in the balance between testosterone, a male hormone, and estrogen, a female hormone present in men in small amounts. Testosterone production declines with advancing age, changing the ratio of testosterone to estrogen. Some animal studies have shown that this shift in hormone balance may start a chain reaction, causing the rapid cell multiplication seen with prostate enlargement. Other animal studies suggest that the accumulation of the male hormone dihydrotestosterone (DHT) in the prostate may encourage cells to divide.
Several large studies over the past decade have suggested a link between prostate enlargement and Western dietary patterns. In 2002, researchers for the 51,529 men participating in the Health Professionals Follow-up Study reported that men with a higher intake of calories, protein, and some specific forms of polyunsaturated fats were more likely to develop an enlarged prostate than those who ate less of these nutrients. A 2007 analysis of the same participants showed that those who consumed the fewest vegetables had the highest risk of developing an enlarged prostate. A 2008 study of 4,770 participants in the Prostate Cancer Prevention Trial came to some similar conclusions: risk rose with a diet low in vegetables and high in total fat, polyunsaturated fat, and red meat. However, this study came to the opposite conclusion about protein, finding that it might actually reduce risk. These studies have also raised questions, because unsaturated fats are generally considered healthy, so it is not clear why they would raise risk of BPH.
Although 50% to 60% of men with BPH may never develop any symptoms, others find that BPH can make life miserable and seek treatment. Interestingly, the size of the prostate does not always predict symptoms. Some men with large glands never have symptoms, while others with small glands do. When problems do occur, patients and their physicians have several medications from which to choose, so if one doesn’t do the trick, another can be prescribed. And thanks to some refinements, surgical treatments are more effective and have fewer side effects than ever before.
Symptoms of BPH
The most common symptoms of BPH involve changes or problems with urination. These are sometimes referred to as lower urinary tract symptoms. They include
How BPH progresses
As the prostate enlarges, it starts to press against the urethra and the bladder (see Figure 1), like a foot stepping on a garden hose or fingers pinching a soda straw. This gradually obstructs the flow of urine, forcing the bladder to work harder to push urine through the urethra. But straining to urinate, although unavoidable, only makes matters worse. Like any muscle, the bladder wall becomes thicker with work. This reduces the amount of urine the bladder can hold and causes it to contract even when it contains only small amounts of urine, causing more frequent urination. Eventually, the bladder becomes so thick that it loses its elasticity and can no longer empty itself.
Figure 1. How BPH progresses
As the prostate gland enlarges, it constricts the urethra, the tube that carries urine out of the body, impeding urine flow. The bladder has to work harder to force stored urine out. Over time, the bladder walls thicken, leaving less and less room for urine.
The narrowing of the urethra and partial emptying of the bladder cause many of the problems of BPH. You may feel as though you have to urinate immediately, yet have to strain to do so. You may have a weak urinary stream or one that stops and starts. You may dribble after urinating or feel as if you’re not emptying your bladder completely. And you may feel the need to urinate frequently—even every few minutes—causing many awakenings during the night. Some men also experience urinary incontinence, the involuntary discharge of urine.
The course of BPH varies from one man to the next. In some, the disease may progress to a certain point and reach a plateau of mild symptoms that never worsen, or the prostate may continue to enlarge but grow away from the urethra, causing no additional impingement. Particularly in the early years of the condition, the symptoms may abate before worsening again. In other men, the disease progresses and the symptoms intensify steadily, year after year. In the worst cases, the prostate can grow as large as an orange.
Most physicians advise against medical or surgical treatment for men with mild symptoms, because the side effects of the treatment outweigh the potential benefits. But if the symptoms worsen, ordinary activities may become a challenge. A 65-year-old man may find it hard to sit through a lengthy meeting without having to excuse himself to use the bathroom. He may need to request an aisle seat at the theater or a sports event, so he can rush to the bathroom at any time. If he has a problem with leakage, he may begin wearing dark clothing to conceal his incontinence. And he may feel fatigued during the day because of frequent nighttime awakenings.
BPH can also produce complications that, while not life-threatening, nonetheless require medical attention. If the blockage is so severe that it keeps your bladder from emptying completely, you may be vulnerable to frequent urinary tract infections. The risk of developing bladder stones also increases. The growth of the prostate can rupture blood vessels in the urethra, causing blood to appear in the urine. If obstructive BPH goes untreated for too long, the bladder may become distended, its muscular wall may weaken, and you may be unable to squeeze any urine past the obstructing prostate gland, a condition known as acute urinary retention. The bladder may become so distended that urine cannot adequately empty from the kidneys. In the most severe cases, this can lead to kidney failure. And not being able to urinate at all is a medical emergency, requiring the temporary passage of a catheter (a thin tube) through the urethra to allow the bladder to drain. Fortunately, such complications are uncommon because most men seek medical attention well before serious problems develop.
If you experience the symptoms of BPH, see your doctor. During an initial evaluation, the doctor will take a medical history. Expect questions about your urinary flow problems, how long the symptoms have been present, and any prior genitourinary surgery or procedures. Most likely, he or she will ask about your health habits and any medications that may have made the symptoms worse. Your doctor may also ask you to complete a questionnaire, such as the American Urological Association Urinary Symptom Score, to help evaluate the severity of your BPH.
Your urinary symptom score
To evaluate the severity of your benign prostatic hyperplasia (BPH) and determine what treatment, if any, might be best for you, your doctor may ask you to complete a questionnaire like the one below. Circle one number to respond to each question, and then calculate the total score.
In general, if your symptoms are mild (scores of 1–7), no treatment is needed. If your symptoms are moderate (scores of 8–19), you probably need some form of treatment, such as medication. If your symptoms are severe (scores of 20 or greater), surgery is likely to be your best treatment option if medications do not improve urinary function.
1.Over the past month, how often have you had a sensation of not having emptied your bladder completely after you finished urinating?
2. Over the past month, how often have you had to urinate again less than two hours after you last finished urinating?
3. Over the past month, how often have you stopped and started again several times while urinating?
4. Over the past month, how often have you found it difficult to postpone urination?
5. Over the past month, how often have you had a weak urinary stream?
6. Over the past month, how often have you had to push or strain to begin urination?
7. Over the past month, how many times, typically, did you get up to
8. How would you feel if you had to live with your urinary condition the way it is now, no better, no worse, for the rest of your life?
An adequate physical exam and diagnostic workup includes a digital rectal examination (DRE) and, if you and your doctor concur, a prostate specific antigen (PSA) test. It also includes several other laboratory tests, such as a urinalysis. This allows your doctor to rule out bacterial infections and look for untreated diabetes, which can produce frequent urination, particularly at night.
In a sense, your lifestyle will determine how burdensome you find BPH. The symptoms that disrupt the day-to-day activities of one man may have less of an effect on another who perhaps spends much of his day at home. Work with your physician to determine what, if any, treatment is the best choice.
When symptoms are not particularly bothersome, you and your doctor may choose to do nothing other than watchful waiting, which involves regular monitoring to make sure you aren’t developing any complications, but no treatment. For more troubling symptoms, most doctors begin by recommending a combination of lifestyle changes and medication. Often this will be enough to relieve the worst symptoms and allow you to avoid surgery. Another option is learning intermittent self-catheterization (see Figure 2).
Tips for relieving BPH symptoms
Should surgery become necessary, keep in mind that there are several surgical techniques available and that just because a technique is new doesn’t mean it is better. Before proceeding, check with your health insurance company to make sure your choice is covered. Not every health plan covers every procedure, and because there are several effective treatments, you may want to choose one that your insurance will cover. Also, if you choose a surgical procedure, find a surgeon who has extensive experience with that specific procedure.
Figure 2: Intermittent self-catheterization for urinary retention
One of the reasons that men who have BPH have to urinate so frequently is that they are unable to completely empty their bladder—a problem known as urinary retention. This is a common complication of BPH. The amount of urine left in the bladder is known as the post-void residual. When the bladder does not empty on a regular basis, a man may feel a constant sense of fullness in his abdomen and a nagging need to urinate, yet when the time comes his urine stream may be weak or intermittent.
Urinary retention is more than an annoyance. A man with significant post-void residual risks urinary tract infections and other medical complications. Incomplete voiding can also affect a man’s quality of life. Men sit on their prostates. Sitting for prolonged periods—such as during business meetings or on airplanes—places extra pressure not only on the prostate but on the bladder, and that can increase the need to urinate. If a man’s bladder is already partly full because of urinary retention, the pressure can become unbearable. Frequent fliers with this problem know the agony of waiting for the seatbelt light to go off so they can reach a bathroom.
If urinary retention is a problem for you, one option that may help is chronic intermittent catheterization. Men who learn this technique can more completely empty their bladder by using a home catheter that is smaller and more portable than the Foley catheters used in medical procedures. Using this technique along with some common-sense additional strategies—such as not drinking a lot of water, alcohol, or caffeinated beverages (all increase urination)—may help you get through the next long plane trip or meeting. Here’s how to practice chronic intermittent catheterization:
Medications that treat BPH
Before suggesting surgery, your doctor is likely to recommend medication for BPH (see Table 1). The FDA has approved three types of drugs for BPH:
- 5-alpha-reductase inhibitors, including dutasteride (Avodart) and finasteride (Proscar, generic)
- alpha blockers, including doxazosin (Cardura, generic), terazosin (Hytrin, generic), alfuzosin (Uroxatral), silodosin (Rapaflo), and tamsulosin (Flomax, generic)
- a PDE5 inhibitor, tadalafil (Cialis)
Table 1: Medications for BPH
|Medication||Potential side effects||Comments|
|dutasteride (Avodart)finasteride (Proscar, generic)||Although uncommon, decreased libido, decreased ejaculate volume, and impotence may occur. (Problems with libido may continue after taking finasteride.)||Help shrink larger prostate glands. Reduce need for surgery. Not beneficial for small prostates. Slow to act; can take up to two years to see full benefits. Can lower PSA levels considerably.May increase risk of aggressive prostate cancer; important to monitor PSA.|
|Alpha blockers (nonselective)|
|doxazosin (Cardura, generic)terazosin (Hytrin, generic)||Dizziness, headache, and fatigue are most common. Nasal congestion, dry mouth, and swelling in the ankles can also occur. Hypotension (low blood pressure), although rare, may pose a danger for some people.||Should be used carefully by those with hypertension or heart disease.|
|Alpha blockers (selective)|
|alfuzosin (Uroxatral)silodosin (Rapaflo)
tamsulosin (Flomax, generic)
|Dizziness, headache, and fatigue are most common. Nasal congestion, dry mouth, and swelling in the ankles can also occur.||Do not lower blood pressure, but men taking silodosin may notice a drop in blood pressure upon standing.|
|dutasteride and tamsulosin (Jalyn)||Dizziness, headache, and fatigue may occur. Hypotension (low blood pressure), although rare, may pose a danger for some people.||Can lower PSA levels considerably.May increase risk of aggressive prostate cancer; important to monitor PSA.|
|tadalafil (Cialis)||Headache, flushing, upset stomach, nasal congestion. Temporary disturbances in color vision possible. In rare cases, may cause priapism, an erection that lasts too long.||Do not take more than one pill in 24 hours. Do not take if you are also taking alpha blockers or nitrate medications, to avoid risk of hypotension (low blood pressure that can cause fainting).|
The FDA has also approved a medication that combines the 5-alpha-reductase inhibitor dutasteride with the alpha blocker tamsulosin (the combination is marketed as Jalyn). These drugs work in different ways to alleviate urinary symptoms, and they often work well together (see Figure 3).
Figure 3: How BPH medications can help
Alpha blockers attach to certain receptors in the prostate, bladder, and urethra, blocking chemical signals that tell muscles in these structures to contract. As a result, the muscles relax, allowing urine to flow more freely.
The 5-alpha-reductase inhibitors block the hormone responsible for prostate growth, eventually causing the prostate to shrink.
Alpha blockers, for example, deal with the “going” problem by relaxing certain muscles in the prostate and urinary tract. The 5-alpha-reductase inhibitors deal with the “growing” problem by reducing the size of the prostate. The 5-alpha-reductase inhibitors act slowly, taking a few months to have an effect. Indeed, you may not see the maximum benefit until you’ve been taking the medication for six months to a year. These drugs work best for men with large prostates. (Your doctor can give you a rough estimate of the size of your prostate by doing a DRE.) Alpha blockers, at least in some men, reduce symptoms much more quickly. In general, alpha blockers are better at relieving urinary symptoms such as difficult or frequent urination. But 5-alpha-reductase inhibitors have a stronger track record for reducing the chance that you’ll need surgery or will experience complications, such as acute urinary retention, that occur when the prostate gland is large. With this in mind, some doctors prescribe both kinds of drugs for men with large prostates.
In addition to treating BPH, the 5-alpha-reductase inhibitors were also tested as a means of preventing prostate cancer. Instead, the FDA concluded that these drugs actually cause a small increase in risk for developing aggressive prostate cancer. If you are taking a 5-alpha-reductase inhibitor for BPH, or taking the combination pill Jalyn (which contains one of these drugs), talk with your doctor about what you should do.
In 2011, the FDA approved the first PDE5 inhibitor, tadalafil, for use in treating BPH and the combination of erectile dysfunction and BPH. It’s not clear why PDE5 inhibitors, normally used to treat erectile dysfunction, help improve BPH symptoms. But after several studies suggested that men taking these erection drugs also found their urinary difficulties subsided, investigators decided to conduct separate studies involving only men with BPH. Two studies concluded that the PDE5 inhibitor tadalafil improved BPH symptoms, and one concluded that it improved both BPH symptoms and erectile function. When used to treat BPH (with or without erectile dysfunction), the medication is taken at a 5 mg dose once daily.
You generally need to take BPH drugs indefinitely to maintain their benefits. If you stop taking the medication, the symptoms usually return to their previous levels. Over all, compared with surgical procedures, medication has a lower risk for serious adverse effects, leading most men to choose drug therapy as their initial treatment.
Alpha blockers. For men with moderate enlargement of the prostate and moderate urinary problems that are too bothersome to simply do nothing, doctors often first prescribe an alpha blocker. Originally approved to treat high blood pressure, alpha blockers relieve urinary symptoms by relaxing the smooth muscle tissue in the prostate and the surrounding capsule. This relieves constriction of the urethra and allows urine to flow more easily.
Alpha blockers come in two forms: selective and nonselective. Because nonselective alpha blockers can lower blood pressure, they aren’t the right choice for every man. Some doctors are hesitant to prescribe nonselective alpha blockers for men who are already on another blood pressure medication. Taking several antihypertensive drugs at once can cause an excessive drop in blood pressure, producing faintness or dizziness, especially when getting up from a chair or out of bed. Sudden episodes of low blood pressure can be dangerous for men with vascular disease, which places them at high risk for a heart attack or stroke. However, the selective alpha blockers are more specific to the prostate and don’t lower blood pressure, making them useful for men who don’t need or couldn’t tolerate this additional effect.
In addition, some men on alpha blockers experience dizziness, lack of energy, swelling of the ankles, or retrograde ejaculation, which occurs when semen flows back into the bladder rather than out through the penis upon orgasm. You may need to make several visits to your doctor and try several prescriptions to arrive at the appropriate medication and the right dose.
5-alpha-reductase inhibitors. These medications help shrink the prostate, but they work slowly and may be less effective at relieving symptoms than the alpha blockers. Finasteride and dutasteride shrink the prostate by changing its hormone balance. Specifically, they reduce levels of the male hormone dihydrotestosterone (DHT), which plays a role in prostate growth. The drugs interfere with the action of 5-alpha reductase, an enzyme that converts testosterone to DHT. Interestingly, their ability to lower DHT levels also makes these drugs useful in treating hair loss in men.
An analysis of six studies comparing finasteride against a placebo found that the medication works somewhat better in men with large prostates, and that it may not be a good choice for those with smaller glands. Subsequently a study involving 3,040 men showed that finasteride provided significant benefits for men with symptoms of urinary obstruction and prostatic enlargement. Patients who took it for four years experienced fewer symptoms, a reduction in prostate size, an increase in urinary flow rate, and less likelihood of needing surgery or experiencing acute urinary retention. Researchers have also reported that finasteride was most effective in men with large prostates and with PSA levels of 1.4 nanograms per milliliter (ng/ml) or higher.
These medications tend to reduce PSA levels by about 50%, although the actual reduction varies. Most physicians advise obtaining a baseline PSA value before beginning treatment with a 5-alpha-reductase inhibitor, and then having another after six months to a year to see how much PSA was affected. If the PSA does not go down by 50%, or if it begins to rise after a man starts taking the drug, a biopsy may be necessary to determine if this is a sign of cancer.
Finasteride and dutasteride can interfere with sexual function. According to one clinical trial, as the drug shrinks the prostate gland, some sexually active men (8.1%) have difficulty achieving erections, and others (6.4%) experience a decline in sexual desire. A few (3.7%) notice a decrease in the volume of their ejaculate, which some may find troublesome. In clinical practice, however, doctors say these side effects are much more common, affecting up to a third of patients.
Why the discrepancy?
The rate of side effects reported in clinical trials is often different from that seen in clinical practice. Researchers may not ask about particular side effects, so unless participants in a clinical trial know to report them, that information won’t be recorded. (This underscores the need for consistent questioning of trial participants during clinical studies.) Also, a doctor may have a closer relationship with a patient than a researcher and may be more inclined to ask about side effects and how bothersome they are.
In 2012, based on reports it received from doctors and patients, the FDA revised the finasteride label to warn about possible sexual side effects. Men who use this drug for BPH should be aware that it may cause poor semen quality (contributing to infertility) and erectile dysfunction, although both problems should improve once they stop taking it. However, the drug may also depress libido, and the FDA warns that this problem may continue even after stopping the drug.
Combination therapy. Because alpha blockers and 5-alpha-reductase inhibitors work differently, researchers have hypothesized that taking both types of medication might be more effective for controlling symptoms than taking just one. After several studies confirmed this, the FDA in 2010 approved a pill—marketed as Jalyn—that combines the 5-alpha-reductase inhibitor dutasteride with the alpha blocker tamsulosin
PDE5 inhibitors. Studies have established a physiological link between erectile dysfunction and the urinary symptoms that accompany BPH. Prescribed for erectile dysfunction, phosphodiesterase-5 (PDE5) inhibitors augment cyclic GMP, a chemical that relaxes smooth muscle in the penis, improving blood flow during sexual stimulation. PDE5 inhibitors—sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra)—also seem to relax smooth muscle in the bladder neck, urethra, and prostate. A handful of clinical trials have shown that these drugs improve both erectile function and urinary symptoms in men with both conditions.
Based on three studies that specifically evaluated the use of PDE5 inhibitors for BPH, in 2011 the FDA approved tadalafil (Cialis) as a stand-alone treatment for BPH-related urinary symptoms and as a dual treatment to address both BPH and erectile dysfunction. Participants took 5 mg of tadalafil a day—at the lower end of the dosing scale when this pill is prescribed for erectile dysfunction. In all three studies, daily tadalafil significantly improved BPH symptoms as assessed through patient questionnaires that asked about issues such as urinary urgency and frequency. In 2012, a randomized controlled study reported that tadalafil worked as well as the alpha-blocker tamsulosin. Based on this evidence, an advisory committee in Europe recommended that the option become available in Europe as well.
Although the fact that an erectile dysfunction drug can also perform “double duty” to relieve BPH may be welcome news to some men, it’s also wise to understand the limitations. Most studies examining the use of PDE5 inhibitors have been relatively short—12 weeks—meaning that researchers have little data on whether they affect the progression of BPH or instead only delay more aggressive treatments. One of the studies involving tadalafil lasted one year, but there are no longer-term data on the safety of this or other PDE5 inhibitors.
The FDA advises men against taking tadalafil with nitrates (such as nitroglycerin), because combining these two drugs may cause a risky drop in blood pressure. Traditionally doctors also advised that tadalafil and other PDE5 inhibitors not be combined with alpha blockers to treat BPH, out of concern that the combination might also dangerously reduce blood pressure. However, the drugs are often used together and in most cases do not cause problems. To be safe, start at the lowest dose possible and try to take the drugs at different times of the day.
A variety of herbal remedies are marketed as BPH remedies, but so far evidence for their effectiveness remains limited. In addition, standardized doses and preparations have not been determined.
Saw palmetto. One herbal remedy often touted for the treatment of the urinary effects of BPH is saw palmetto, which is made with extracts of the fruit of the saw palmetto plant (serenoa repens). The active ingredients are thought to be the various sterols, or hormone-like substances, in the plant extract. American Indians have long used saw palmetto as a diuretic. But while early studies of various saw palmetto products concluded that the supplements moderately improve urinary tract symptoms and urine flow, more recent—and better-designed—studies have concluded otherwise.
A review conducted for the Cochrane Collaboration, an international group of experts, examined 17 randomized controlled trials that compared saw palmetto with placebo. The review found that saw palmetto was no better than a placebo at improving urinary flow or otherwise relieving symptoms of BPH—even in studies where saw palmetto was given at double or triple the usual dose.
One of the studies include in the review was a federally funded trial published in 2011. The multisite study included nearly 370 men older than 45 who had moderate symptoms of BPH. Over 72 weeks, the participants took a daily dose of either saw palmetto or placebo. As the study progressed, the standard dose of 320 mg/day of saw palmetto was tripled. Despite the increase in dose, however, at the end of the study saw palmetto did not work any better than placebo.
In addition to its lack of effectiveness, another drawback of this herbal supplement, as with most nonprescription herbal products, is that its composition and dosage have not been standardized, and the FDA doesn’t regulate it. If you decide to use saw palmetto in spite of the negative research, tell your doctor so he or she will be alert to possible interactions between it and any other medications you take.
Pygeum africanum. This extract of an African prune tree is sometimes used as a treatment for urinary symptoms. While this substance may modestly improve urologic symptoms and flow, it’s not clear how effective it is compared with standard medical interventions, such as alpha blockers or 5-alpha-reductase inhibitors. Nor is there information about whether it prevents long-term complications of BPH, such as acute urinary retention.
Beta sitosterols. Preparations containing beta sitosterols—derived from the South African star grass—are sometimes used to treat symptoms of BPH. These substances may improve urinary flow and other BPH symptoms, but their long-term effectiveness, safety, and ability to prevent BPH complications are unknown.
If the results of watchful waiting and medication or other therapies are not satisfactory, you and your doctor will need to determine whether surgery or another procedure may be right for you. In the past, if BPH symptoms were severe—or if they were modest but still disrupted a patient’s life—doctors almost universally recommended a surgical procedure called transurethral resection of the prostate (TURP). Although TURP is still widely used and is considered the gold standard by many doctors, alternatives are available. Explanations of the most common procedures are below; for a comparison of procedures, see Table 2.
Table 2: BPH procedures compared
|Procedure||What’s involved||Success rates||Side effects|
|Transurethral resection of the prostate (TURP)||Performed in operating roomRequires general or spinal anesthesia
May require one to two days in the hospital, with catheter inserted to enable urination for one to three days
Heavy physical activity may be restricted for two weeks or more to prevent bleeding
Full recovery may take four to six weeks
|Provides symptom relief in at least 85%–90% of men treated||May cause erectile dysfunction or ejaculatory problems (retrograde ejaculation)Blood loss, urinary incontinence, infections, and complications from anesthesia are uncommon but do occur|
|Photoselective vaporization of the prostate (PVP or GreenLight)||Most patients treated in outpatient settingCatheter remains in place at least overnight for most patients
Patients can resume light activity and return to work within two to three days
Patients can resume vigorous activity in four to six weeks
|Improvement in symptom relief similar to TURP||Ejaculatory problems similar to TURPLess bleeding than TURP
Urinary frequency or urgency in first month
No tissue sample available to check for prostate cancer
|Transurethral microwave thermotherapy (TUMT)||Performed on outpatient basis in a doctor’s officeAnesthesia not needed, though pain medication and sedatives may be needed
Procedure takes about one hour
Catheter needed for several days
|More effective than medication but less effective than TURP||Some urinary side effects, such as frequent urination or discomfort during urination, that can last for several weeksRisk of reoperation greater than with TURP|
|Transurethral incision of the prostate (TUIP)||Small incisions are made in the prostate to relieve constriction of the urethraRequires anesthesia
Hospital stay is typically one to three days
Usually reserved for men with a small prostate
|About 80% of patients report an improvement in urinary symptoms||Likelihood of urinary retention is greater than with TURPRisk of reoperation greater than with TURP|
|Transurethral electrovaporization of the prostate (TUEVP)||Electrical current vaporizes overgrown prostate tissueOvernight hospital stay
Catheter needed for one to two days, but usually for less time than with TURP
|As effective as TURP at relieving symptoms and improving urine flow, but higher risk of needing second operation||Likelihood of urinary retention is greater than with TURPRisk of reoperation greater than with TURP
Some urinary side effects, such as blood in the urine and irritation when urinating, that can last for a few weeks
|Transurethral needle ablation of the prostate (TUNA)||Done on an outpatient basisMay need local anesthesia
Catheter usually not needed
|More effective than medication but less effective than TURP||One study reported that 14% of patients need additional treatmentsSide effects, such as erectile dysfunction and urinary incontinence, less common than with TURP|
Transurethral resection of the prostate (TURP). TURP, often inelegantly referred to as the “roto-rooter” technique, is an incision-free surgical procedure that cuts away excess prostate tissue with an electrical loop. TURP remains the most common form of prostate surgery and is usually more successful than medication. It relieves urinary obstruction in at least 85% to 90% of men, and the improvement is usually long-lasting. However, urinary problems can recur if the prostate tissue grows back. Not surprisingly, the younger you are, the more likely it is that you’ll eventually need another treatment.
The hour-long procedure takes place in an operating room under general or spinal anesthesia, given just before the operation begins. Typically, you will have an enema the preceding night and will be told not to eat or drink for eight hours before the anesthesia. During the procedure, the surgeon uses an instrument called a resectoscope to view the prostate (see Figure 4). The surgeon threads the resectoscope through the penis to the prostate, then uses the electrical loop to cut away the overgrown tissue that’s pressing against the urethra. You may spend one to two days recovering in the hospital. While recovering, you urinate through a thin tube, or catheter, inserted into the bladder through the penis. Once home, you may have to restrict heavy physical activity for two weeks or more to prevent bleeding.
Figure 4: Transurethral resection of the prostate (TURP)
During transurethral resection of the prostate (TURP), the surgeon inserts a thin tube called a resectoscope into the urethra and threads it up into the enlarged prostate (A). The resectoscope contains a tiny camera allowing the surgeon to view the gland throughout the operation, as well as an electrical loop. The surgeon uses the loop to chip away at overgrown prostate tissue blocking the urethra (B). After the procedure, the enlarged passageway allows urine to flow more easily (C).
Most men who’ve had TURP experience retrograde ejaculation during sexual activity—that is, the semen does not come out of the penis, but instead flows backward into the bladder. This occurs because the surgery destroys the valve that would ordinarily prevent this from happening. The semen is later flushed out with the urine. While not harmful to your health, retrograde ejaculation does make it more difficult to father children, a factor that you must weigh when considering TURP if you have not yet completed your family.
The more worrisome complications of TURP occur in about 5% to 10% of patients. These include blood loss, impotence, urinary incontinence, infections, and complications related to the anesthesia. The risk of complications needs to be considered when choosing treatment options, but TURP remains the gold standard of treatment for BPH. Interestingly, a study of U.S. veterans has suggested that TURP is no more likely to cause sexual problems or incontinence than watchful waiting.
About 2% of men who have the procedure develop TURP syndrome, which causes symptoms such as confusion, nausea, vomiting, high blood pressure, and visual distortions. The syndrome develops as a complication of the fluid used to keep the surgical area clean during TURP. Such “irrigation fluids” are used in all sorts of surgery, but the solution used depends on the procedure. Traditionally, the irrigation fluids used most often during TURP are glycine or a combination of sorbitol and mannitol. Although generally safe, in some men these solutions can promote fluid buildup. There is also some evidence that at high levels glycine may be toxic to the liver, kidneys, and pancreas.
A safer alternative is saline solution—used in many other types of operations—but until recently this solution could not be used in TURP because saline conducts electricity and can interfere with the electrical charge delivered by a traditional resectoscope. A new type of resectoscope, using a different type of electrical grounding device, is designed to work with saline solution. Known as a coaxial continuous-flow bipolar resectoscope, the device is more expensive than traditional resectoscopes but may offer an alternative to men at risk for TURP syndrome, or who have had it in the past.
On rare occasions, TURP isn’t a good option because the prostate has grown too large. Instead, open prostatectomy is necessary. In this procedure, the surgeon removes tissue blocking the urethra through an incision in the lower abdomen, leaving the rest of the prostate gland in place. Generally, this operation requires a longer hospital stay. On the other hand, compared with TURP, it reduces the likelihood that the tissues will grow back or that problems will recur.
Transurethral electrovaporization of the prostate (TUEVP or TVP). This procedure is similar to TURP in that a resectoscope is inserted into the penis and threaded up into the prostate. But instead of a wire loop that cuts away overgrown prostate tissue, the resectoscope has a roller-ball electrode at the end. Electrical energy quickly heats, vaporizes, and cauterizes prostate tissue, minimizing bleeding. A catheter is then inserted into the bladder.
A meta-analysis of 20 studies examining the safety and effectiveness of TUEVP compared with TURP concluded that, after one year, there was no significant difference in urinary symptom scores or urinary flow rates. The men who underwent TUEVP were significantly less likely to require a blood transfusion. They also spent less time in the hospital and didn’t need catheterization for as long as TURP patients. But the TURP patients had a lower risk of urinary retention after the surgery and were less likely to need a second operation compared with TUEVP patients.
Transurethral incision of the prostate (TUIP). TUIP also involves inserting an instrument into the prostate via the penis. But rather than cutting away excess tissue, the surgeon makes one or more deep lengthwise incisions in the prostate at the site of the urethral constriction. This opens the urethral passage, relieving pressure on the urethra and improving urine flow. Spinal or general anesthesia is generally used for TUIP, which can be performed on an outpatient basis or during a one-day hospital stay. Recovery usually takes five to seven days.
TUIP is not an option for every patient. Men with small prostates are the usual candidates for this procedure. The benefits appear to last: over a five-year period, the chance of needing further surgery is 8% to 10%, somewhat higher than the comparable figure for TURP (5%). There appear to be fewer postoperative complications—including retrograde ejaculation, urinary incontinence, and blood loss—than with TURP. A quarter of men who’ve undergone TUIP experience retrograde ejaculation, but more than 70% of those who’ve had TURP do. As a result, most TUIP patients remain fertile after the procedure. Consequently, this option is the one often chosen by men with only moderately enlarged prostates who may still want to father children.
Laser surgery is widely available for treating BPH, and is increasingly being used instead of TURP. Although usually performed in a hospital setting, laser surgery is less traumatic than TURP, and most patients go home the same day.
To perform a laser procedure, the surgeon begins by guiding a fiber through the urethra to the prostate. This fiber conducts the laser light to the target area. Then the surgeon uses the laser to burn away tissue that obstructs the urine flow. Dead tissue that’s not immediately vaporized is later expelled in the urine. This technique destroys prostate tissue with less bleeding than standard TURP. However, because tissue is vaporized, a pathologist cannot check it for cancer, as may be done with TURP.
Surgeons may also use other types of lasers. For example, procedures using high-energy lasers—like the KTP laser—involve less blood loss, shorter hospital stays, and less time with a catheter compared with TURP. However, use of the holmium laser and its relatives is somewhat limited because they require extensive training and experience compared with
Surgeons originally used low-energy lasers for these procedures. Now high-energy lasers are becoming more popular. The advantage of these over TURP or low-energy laser sources to remove prostate tissue is that bleeding is reduced and the catheter may be removed much earlier, often within 24 hours. Overnight hospitalization often is not needed. One type of high-energy laser, called a KTP laser, is used during a procedure called photoselective vaporization of the prostate (PVP). During PVP, the surgeon can view the prostate and remove large amounts of tissue with little bleeding (see Figure 5). Indeed, even patients on blood-thinning medication may undergo PVP while still taking their medications.
Figure 5: Photoselective vaporization of the prostate (PVP)
When an enlarged prostate obstructs urine flow (A), a relatively new laser technique may be used instead of TURP. During photoselective vaporization of the prostate (PVP), also called the GreenLight procedure, the surgeon threads a thin tube called a cystoscope through the urethra into the enlarged prostate. The surgeon then threads a fiberoptic device through the cystoscope to generate high-intensity pulses of light, which simultaneously vaporize the obstructing tissue and cauterize it to reduce bleeding (B). This creates an enlarged, uniform channel through which urine can flow (C).
Laser procedures have increased in popularity over the past decade. One analysis of data in Florida—a state with a large elderly population and thus, presumably, men affected by BPH—found that laser procedures had increased 400% between 2001 and 2009. In a surprise, however, the patients least likely to receive laser treatment for BPH were men who were older or in ill health, two factors that might make an office-based laser procedure seem more appealing than going into the hospital for TURP.
There is no proof yet that laser procedures are any better than TURP in the long term. Research suggests that patients who have laser procedures are just as likely to experience urinary incontinence and retrograde ejaculation as are those who undergo TURP. And a large study reported in 2012 that men who undergo laser procedures are more likely to need additional treatment for BPH symptoms than those who undergo TURP. The study found that about 8% of men who underwent TURP needed another procedure within four years, compared with 13% of men who had a laser procedure.
Other treatments for BPH
A variety of other treatments for BPH are in use. Some are not available everywhere, some aren’t covered by health insurance, and some are investigational, meaning that they are available only as part of a clinical trial. However, they can be viable options for certain patients with BPH, such as men who aren’t healthy enough for surgery.
Transurethral microwave thermotherapy (TUMT). TUMT is one of a group of techniques, known as “heat therapies,” that use heat to destroy prostate tissue, achieving results similar to TURP. In TUMT, the doctor guides a thin catheter carrying a miniature microwave generator through the penis to the prostate. There, microwaves destroy some of the prostate tissue and relieve pressure on the urethra (see Figure 6). A cooling jacket around the generator protects the urethra. The procedure takes about an hour and can be performed on an outpatient basis.
Figure 6: Transurethral microwave thermotherapy (TUMT)
A thin catheter carrying a miniature microwave generator is guided through the penis to the prostate. Microwaves heat the prostate, destroying the tissue that obstructs urine flow. A computer receives temperature information from the catheter and rectal probe and halts therapy if the areas get too hot.
TUMT appears to be less effective than TURP. A 2001 study reported that 18% of men who underwent TUMT needed additional treatment after 36 months, compared with 13% of those who received TURP. A 2012 analysis of 15 studies of the procedures found that TURP also yielded greater improvements in urine flow and urinary symptoms than TUMT. However, compared with TURP, TUMT results in no blood loss, fewer surgical complications because anesthesia isn’t needed, and less risk of retrograde ejaculation.
Transurethral needle ablation (TUNA). TUNA is a thermal approach that uses low-level radio waves delivered through twin needles to heat and kill obstructing prostate cells. Shields protect the urethra from damage
A randomized, prospective clinical trial published in 2004 compared the safety and effectiveness of TUNA with TURP. Researchers at seven centers in the United States enrolled 121 men in the trial; 65 underwent TUNA, and 56 had TURP. Over five years, both groups of men reported significant improvement in symptoms, quality of life, urine flow, and post-void residual volume. But in most cases, the improvements were greater among the TURP patients. Only 1.8% of patients who had TURP needed a second procedure, for example, compared with 13.8% of TUNA patients.
However, patients undergoing TURP experienced more adverse events or side effects of the procedure than patients undergoing TUNA. For example, the incidence of erectile dysfunction following TUNA was 3.1%, versus 21.4% for TURP. None of the patients in the TUNA group experienced retrograde ejaculation, but 41% of the patients who underwent TURP did.
Prostatic urethral stents. A prostatic urethral stent is a small, springlike mesh cylinder. The doctor inserts the stent through the penis and, after positioning it in the narrowed area of the urethra, releases it to widen the channel, relieving pressure from the prostate tissue and allowing for easier urination. This quick procedure requires only local or spinal anesthesia, involves no loss of blood, and is often done in an outpatient surgical center.
Prostatic urethral stents are most often used in elderly men who have severe prostate enlargement and whose overall health is so poor that surgery would be risky. In many cases, urinary obstruction gradually returns because of a process called hyperplastic epithelial reaction, in which prostate tissue protrudes through the mesh and causes renewed blockage. Additional procedures may be required in some cases.
Botulinum toxin (Botox). Popularly used to minimize facial wrinkles, botulinum toxin is being investigated for relief of urinary symptoms in men with enlarged prostates. It won’t shrink your prostate, but small studies have shown that botulinum toxin injections reduced pain and other urinary symptoms—and improved quality of life—for men with BPH. While that may sound promising, there’s still a lot that isn’t known about using botulinum toxin for the treatment of BPH, such as its long-term effectiveness, its impact on sexual function, the best injection sites, and the appropriate dose. If you decide to try botulinum toxin injections, do so only as a participant in a clinical trial.
NX-1207. This compound apparently works in a different way from other BPH drugs. The studies published so far suggest that it causes prostate cells to die off in an orderly fashion (a process known as apoptosis). A physician injects the drug directly into the prostate by using a catheter that slides into the rectum. Treatment takes place in a physician’s office, involves only one injection, and doesn’t require anesthesia.
In 2011, the company that makes NX-1207 announced preliminary results of one of its phase III trials, reporting that the compound doubled the BPH symptom relief offered by currently available drugs. They also claimed that a single injection of NX-1207 could continue working for up to seven and a half years. Since then, the company has launched another phase III trial to evaluate the safety and efficacy of a repeat injection of NX-1207 in 200 men who had participated in an earlier study of the compound.
Too good to be true? Maybe. Independent researchers have expressed skepticism about these results, particularly because the company developing NX-1207 has not made crucial details—such as what exactly the compound is made of—public. Moreover, none of the phase III studies have yet been published in a peer-reviewed journal—a process that allows independent investigators to evaluate the strength of the findings. And a search of the medical literature reveals no insight into how NX-1207 works.
Adding to the intrigue, the company has started a Phase II clinical trial to test NX-1207 for use in low-risk, localized prostate cancer. This research is at an earlier stage than the BPH trials, and is being conducted to determine what dose of the compound is safe to use. The company announced in September 2012 that so far the doses being tested appear safe—but there are no data yet on whether the compound has any effect on prostate cancer. Some commentators have referred to NX-1207 as a mystery compound. One analyst who examined patent applications filed by the company that is developing NX-1207 claims that the compound was discovered while researchers were studying what causes Alzheimer’s disease, a dementia that occurs as brain cells die off. Supposedly researchers have isolated the protein responsible for killing brain cells, and modified it so that it can kill prostate cancer cells—although that is a matter of speculation for now, as the company developing the drug is keeping everything under wraps.
For now, while NX-1207 is worth keeping track of, it’s really too soon to say how effective it is for BPH or prostate cancer.