An enlarged prostate triggers the condition known as benign prostatic hyperplasia.

© Peter Junaidy | Dreamstime.com

Until now, your prostate has given you little cause for concern. But now that you’re older, it’s commanding attention. You have benign prostatic hyperplasia, and your prostate—normally as small as a walnut—is now the size of a baseball, and it’s wreaking havoc on your lifestyle. You wake up several times at night to visit the bathroom. When you’re on the road, you need to pull over every few miles for a restroom break. Or, on the flip side, your enlarged prostate may cause you to struggle to urinate, or feel as if you never fully empty your bladder. Fortunately, an array of medications, interventional treatments, and surgery can help relieve benign prostatic hyperplasia symptoms and help improve your quality of life.

What Is Benign Prostatic Hyperplasia?

The prostate is situated next to the bladder and surrounds the urethra, the tube that carries urine from the bladder. In benign prostatic hyperplasia, or BPH, the prostate swells and presses against the urethra, restricting urine flow and weakening the bladder so that it only partially empties.

The decline in bladder function and urethral obstruction causes BPH symptoms, increased urinary frequency, nighttime urination (nocturia), a greater urge to urinate, a weak urine stream, or difficult or intermittent urination.

Inform your doctor if you experience any of these symptoms. Benign prostatic hyperplasia is rarely life-threatening, but it can result in bladder and kidney damage, bladder stones, and urinary tract infections. Your physician also must rule out other potential causes of your symptoms, such as prostate cancer.

Medical Treatment Options

If you’re bothered enough to seek treatment for benign prostatic hyperplasia, your doctor initially may recommend one or more medications, such as:

• Alpha-blockers: These drugs—alfuzosin (Uroxatral), silodosin (Rapaflo) and tamsulosin (Flomax)—relax the smooth muscles in the bladder neck and prostate to improve urine flow. The medications work fairly quickly, and many patients see improvements within a few weeks. Potential side effects include dizziness, headache, and ejaculation problems. The drugs, especially tamsulosin, have been associated with intraoperative floppy iris syndrome, a complication that occurs during cataract surgery. So, delay alpha-blocker treatment until after cataract surgery, and be sure your ophthalmologist knows if you’re taking any of these drugs.
• 5-alpha reductase inhibitors (5-ARIs): These medications—dutasteride (Avodart) and finasteride (Proscar)—shrink the prostate and are especially useful for men with larger prostates. The drugs may alter the results of PSA screening for prostate cancer and may cause side effects such as erection problems, decreased ejaculation, reduced sex drive, and breast tenderness/mild enlargement. Also, two major trials found that use of 5-ARIs was associated with a slightly higher risk of aggressive prostate cancer, but later analyses seemed to put these concerns to rest.
• Anticholinergics/Beta-3 agonists: Anticholinergic medications—examples include oxybutynin (Ditropan), solifenacin (Vesicare) and tolterodine (Detrol)—decrease the strength of bladder contractions to help reduce urinary urgency, frequency, and nocturia. They may be prescribed for men who continue to experience bladder dysfunction even after their prostate size has been reduced. The drugs may cause dry mouth, constipation, and headache.

  A newer option for these patients is the beta-3 agonist mirabegron (Myrbetriq), which works by actively relaxing the bladder. Potential side effects of mirabegron include headache, constipation, cold-like symptoms, urinary tract infections, and blood pressure increases. (Note: Neither the anticholinergics nor mirabegron are indicated for men with problems emptying their bladder due to benign prostatic hyperplasia.)

• Tadalafil: For men with both BPH and erectile dysfunction, daily-dose tadalafil (Cialis) may be prescribed to treat both conditions.

Minimally Invasive Procedures

For BPH patients who don’t respond to medical therapy or cannot tolerate the side effects, surgery or one of several newer interventional procedures may be necessary.

The standard surgery for benign prostatic hyperplasia is transurethral resection of the prostate (TURP), in which a physician feeds an electrically charged loop through an endoscope into the urethra to remove enlarged prostate tissue. Although minimally invasive, TURP may cause temporary impotence and/or urinary incontinence, as well as bleeding and retrograde ejaculation, in which semen enters the bladder rather than exiting the penis during orgasm.

These days, more and more urologists are using minimally invasive treatments that employ high-energy sources (e.g., lasers, bipolar energy, and water vapor) to vaporize the excess prostate tissue. These vaporization procedures generally provide rapid symptom relief, result in less bleeding, and offer shorter recovery times compared with TURP. However, they may still cause some increased urinary urgency or frequency for a few weeks, as well as urinary tract infections, and retrograde ejaculation.

The vaporization procedures may not be suitable for men with larger prostates. Instead, traditional open surgery or a minimally invasive laser treatment known as holmium enucleation of the prostate (HoLEP) may be required. Like the vaporization procedure, HoLEP is associated with less bleeding and a faster recovery time compared with TURP. However, HoLEP may cause side effects, including increased urinary urgency and frequency (temporary), urinary tract infections, and retrograde ejaculation.

New BPH Intervention Treatment

One of the newer interventional treatments for benign prostatic hyperplasia is the prostatic urethral lift (UroLift) system. In this procedure, small implants placed in the prostate pull back the enlarged tissue out of the way so that it no longer blocks the urethra. Studies suggest that the treatment can improve urine flow and symptoms within two weeks, with minimal side effects.

Additionally, research continues into prostatic artery embolization (PAE), a catheter-based treatment in which microscopic beads inserted into the prostatic artery temporarily block blood flow to the prostate and cause it to shrivel. Although long-term data on this treatment are lacking, some evidence suggests that PAE may be beneficial for some men. For example, in a small study presented at the Society of Interventional Radiology’s 2016 Annual Scientific Meeting, researchers reported that PAE helped reduce nocturia episodes and improved quality of life in 68 men with symptomatic BPH.

“Waking in the night with an urgent need to urinate, or nocturia, significantly disrupts the lives of men by preventing them from having a full night’s sleep,” lead study author Sandeep Bagla, MD, of the Vascular Institute of Virginia, said in a statement. “For many men, the cause of their discomfort is an enlarged prostate, and these results show men can live a more normal life once they’ve undergone PAE to address this condition. For these individuals, PAE has the added benefit of being less invasive compared to other treatments and is performed on an outpatient basis, allowing many men to go home the same day.”