Experiencing lower urinary tract symptoms is very common as we age, it however can be a very life-altering problem for a man. Many causes exist for symptoms such as urgency or frequency of urination, slow stream, a stream that stops and starts, urinating frequently at night, etc. Here we will specifically discuss lower urinary tract symptoms secondary to BPH (benign prostate hypertrophy). BPH is one of the most common diagnoses in men over the age of 40. In fact, approximately 50% of men over this age will have some urinary symptoms. The main indications for treatment are due to quality of life issues (getting up a lot at night to urinate and losing sleep, bothered by your ability to urinate, etc.) urinary retention, recurrent urinary tract infections, bladder stones, or evidence of damage to the kidneys thought to be due related to poor emptying.
This is a plumbing problem for a man, to void he requires that his brain and spinal cord coordinate relaxation of his external sphincter and bladder neck (this keeps him dry when not voiding), while also coordinating bladder contraction or squeezing to expel urine. This is exactly the opposite of when not trying to urinate. Many different pathologies can contribute to lower urinary tract symptoms including but not limited to prior surgery, kidney stones, tumors, prior traumatic injury, social habits including alcohol/smoking/drug use, prior radiation, medication or supplement use, caffeine, old age, etc. Please discuss with your doctor if you feel any of these may be contributing to your symptoms.
As seen in the picture to the right the bladder sits on top of the prostate and the urethra (the tube that drains the bladder) runs directly through the middle of the prostate. As men age, we see that the prostate continues to grow. In fact, based on autopsy data for each decade after 50 the percentage of men with BPH increases to that percentile: So for instance, 70% of men over the age of 70 have BPH. The problem with this is that there is an outer shell or capsule and the bones of the pelvis around the prostate tissue so instead of growing outward, as the tissue grows it grows inward and this decreases the size of the tube or upward and causes a “ball valve” similar to a one-way flap valve in plumbing terms called a “median lobe” of the prostate to grow. This decreased size equals more difficulty and more pressure required to empty the bladder. What we try to achieve with treatment is opening the size of the lumen of the tube or removing the flap valve and making it easier for men to urinate with fewer symptoms.
1st treatment option is oral medications:
- Alpha Blockers (Flomax, Uroxatral, Rapaflo) which work by relaxing the bladder neck and prostatic urethra. These medications are little less than half as effective as having a procedure or surgery done in terms of symptom scores for patient’s before and after surgery. Most current literature suggests that these medications change the patient’s AUA or IPSS symptom score by about 4-6 points. Previous literature suggests that a change in at least 4 points is considered a significant quality of life change. These medications do have some side effects including low blood pressure, lightheadedness, dizziness, retrograde ejaculation (movement of the semen into the bladder during ejaculation instead of out the end of the urethra; this is not harmful), etc it should be noted.
- 5 Alpha Reductase Inhibitors (Finasteride, Proscar) which worked to inhibit the production of the most potent form of testosterone. This acts to limit the growth of the prostate. Previous research has shown that the combination of alpha blockers and 5 alpha reductase inhibitors for prostate over 40 g help prevent patients from the need to have surgery or having a catheter placed due to retention. These medications are associated with side effects like low testosterone or hypogonadal males with changes in mental clarity, libido, central obesity, glucose tolerance, muscle mass, erectile function, etc.
- Anticholinergic Agonists (Ditropan, Trospium, Toviaz, VESIcare) these medications are typically reserved for patients who have more irritative symptoms like urgency frequency urgency incontinence related to irritation of the bladder from an enlarged prostate or from procedures performed as a treatment for enlarged prostate. Some patients also benefit from limiting dietary exposure to caffeine, alcohol, spicy foods, nicotine.
The 2nd treatment option is an in-office procedure called Rezum.
This is a water vapor based procedure in which a camera and a small needle are used to deliver treatments to the inner 30% of the prostate. This can be performed in approximately 10 minutes in the office. This will require a catheter be placed for approximately 2-3 days after the procedure, and a 2nd internal catheter to be placed for 2-3 weeks while you heal if your prostate is greater than 80-100 cc in size or you had retention prior to the procedure. This is the least invasive procedure to have on the prostatic urethra to attempt to clean the pipes so to speak, that is to clear any obstruction and form a nice clean tube to drain the bladder through. There are some side effects that include bleeding, infection, pain, burning, the urgency of urination, frequency of urination, need for a prolonged catheter, need for a repeat procedure, retrograde ejaculation, erectile dysfunction, etc.
The beauty of this revolutionary and new technique is that given its minimal invasiveness, the sexual side effects including retrograde ejaculation, and erectile dysfunction are minimized compared to all of the other treatments on the market today. This would typically be performed in the office with oral sedation and local anesthetic. In comparison to medications, a change in symptoms cores is approximately 12-14 points or expected about 50% reduction in symptom score. The newest literature that was recently published suggests a durable result of rezume at least 5 years. Some limitations include the size of the prostate and use of anticoagulation medications, please discuss these with your doctor.
The 3rd option includes a product called Urolift.
This is a surgically implantable device that works to “open the curtains” of the lateral lobes of the prostate. If we look at the diagram to the right, we can see the differences in an open prostatic urethra, middle lobe hypertrophy, bilateral lateral lobe hypertrophy, and triple lobe hypertrophy. These are the 3 most common configurations we can see of benign prostatic growth. Your doctor would be able to diagnose your configuration based on a cystoscopic examination. Again, the goal is to achieve a free-flowing pipe for urine to easily pass through. If we look at the bilateral lateral lobe hypertrophy example on the bottom to the left, this is the most appropriate setting for Urolift. Essentially this procedure can be seen as tacking the lateral lobes of the prostate back toward the sidewalls to allow for free-flowing of urine. Typically, if you have median lobe hypertrophy we should avoid Urolift as a potential treatment option. This is a safe and effective treatment that has less sexual side effects than surgical options below, and also has good but lower symptom score reduction than rezum at 5 years post-procedure. There was also at least 14.5% of patients that need a second procedure prior to 5 years for further symptoms, and another 10% that restarted medications.
The 4th option includes doing an outpatient surgery with either a GreenLight laser or a TURP (transurethral resection of the prostate).
These are used similar to the Rezum but are a surgeon dependent way to core out the inner portion of the prostate. This is typically done to remove a larger percentage of the inner portion of the prostate. This does require general anesthesia. Similar side effects can be found with these surgical procedures as with the office-based Rezum procedure above. Similar changes in symptoms course can be found as with Rezum and these results have been shown to be durable beyond 5-7 years. In particular for very large prostates 100-120 g and above or patients that are on anticoagulation medications and cannot stop them, the GreenLight laser can be a useful tool to safely perform surgery in this setting.
There is typically a 75% or greater risk of retrograde ejaculation with these procedures and minimal but not unheard of 5-15% of erectile dysfunction risk. Again, as the amount of tissue removed increases the risk to the structures outside of the prostate gland and the chance that some changes in function occur increases as well. Typically GreenLight Laser is preferred in my hands because it offers an outpatient procedure, less blood loss, and a decreased catheter time compared to TURP. This procedure can be an effective outpatient procedure, even for prostates as big as 286 grams in size.
The 5th option that exists is an inpatient robotic or open simple prostatectomy.
This can be thought of as removing the entire inner portion of the prostate leaving only the capsule. Like removing the entire inner portion of an avocado. Obviously, this is a more invasive procedure and it has higher risks. This is typically done for extremely large prostates greater than 130-150 g. This requires general anesthesia and typically a 1-2 night stay in the hospital for recovery prior to discharge home. Patients will typically have to have a catheter for approximately 10 days. The risks of this surgery include bleeding, infection, pain, DVT, PE, heart attack, stroke, death, need for blood transfusion, need for 2nd procedure, erectile dysfunction, ejaculatory dysfunction, bowel injury, need for colostomy, etc. As this is a much longer procedure than any of the above this also requires medical or cardiac clearance.
The 6th option is experimental studies.
There is currently a study with embolization of the prostatic arteries as a treatment for enlarged prostate. This procedure is not performed by myself, and would likely require consultation with interventional radiologists for the risks, benefits, and applicability to your clinical situation.
If you are interested in any of these options please discuss it with Dr. Wallen.
Dr. Jared J. Wallen
Prostatectomy: The 5th option that exists is an inpatient robotic or open simple prostatectomy. This can be thought of as removing the entire inner portion of the prostate leaving only the capsule. Like removing the entire inner portion of an avocado. Obviously as this is a more invasive procedure and it has higher risks. This is typically done for extremely large prostates greater than 130-150 g. This requires general anesthesia and typically a 2-3-night stay in the hospital for recovery prior to discharge home. Patients will typically have to have a catheter for approximately 10 days. The risks of this surgery include bleeding, infection, pain, DVT, PE, heart attack, stroke, death, need for blood transfusion, need for 2nd procedure, erectile dysfunction, ejaculatory dysfunction, bowel injury, need for colostomy, etc. As this is a much longer procedure than any of the above this also requires medical or cardiac clearance.
The 6th option is experimental studies. There is currently a study with embolization of the prostatic arteries as a treatment for enlarged prostate. This procedure is not performed by myself, and would likely require consultation with interventional radiologists for the risks, benefits, and applicability to your clinical situation.
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If you are interested in any of these options please discuss it with Dr. Wallen.