What's up, Doc? Many options exist for treating benign prostatic hyperplasia

Dr. Jeff Hersh
·4 min read
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Q: My enlarged prostate has been causing me to have to get up multiple times in the evening to go to the bathroom. I read that prostatic stents may help me avoid surgery. Is this a good option?

A: The prostate produces the fluid that nourishes and transports sperm (seminal fluid). It's located just below the bladder, surrounding the beginning part of the urethra (the tube that carries urine from the bladder through the penis). If it enlarges enough (becomes hyperplastic), it can "squish" the urethra, compromising the flow of urine.

An enlarged prostate not due to prostate cancer, called benign prostatic hyperplasia (BPH), is common — it affects up to 70% of men in their 60s and 80% of men over age 70. I will often tell men it's not a matter of "if" their prostate will enlarge, but "when."

Dr. Jeff Hersh
Dr. Jeff Hersh

Although some patients may experience minimal symptoms, more bothersome ones such as a frequent need to urinate (including waking the patient up at night); difficulty starting and/or maintaining a urine stream; limitation of emptying the bladder; and/or other symptoms are also common.

Benign prostatic hyperplasia may be suspected, based on symptoms and/or a physical exam (where the clinician palpates the prostate during a rectal exam). It may be evaluated by certain tests such ultrasound, MRI, bladder volume measurements before and after urination, uroflowmetry, pressure flow studies and others.

Cases in which the patient is not able to pass urine to the point where their bladder starts to overfill (complete or near complete obstruction) are a medical urgency/emergency. This requires urgent treatment, and is typically treated in the short term with a foley catheter (a tube placed into the urethra to allow continuous passage of urine).  But for most patients whose symptoms are more gradual in onset, there are many possible treatment options for them to consider.

The best treatment for an individual patient depends on several factors, including the size of their prostate; the potential efficacy of the specific treatment for that patient; possible side effects of the treatment; and very importantly, their preferences. Treatment options follow.

1.) Treatments that focus on symptoms:

  • Lifestyle modifications, such as limiting fluid intake before bedtime (or other times when it may be difficult or inconvenient to go to the bathroom to urinate); avoiding certain medications and foods that may stimulate urination (such as diuretic medications and caffeine); and practicing certain voiding techniques (such as urinating at specific time intervals).

  • Certain medications; for example, alpha-adrenergic receptor blockers.

2.) Treatments that displace prostate tissue to allow for urine passage:

  • A prostatic urethral lift, which mechanically opens the prostatic urethra by compressing some of the obstructing prostate tissue using a specialized device and procedure.

  • Creating a surgical incision with a special instrument inserted into the urethra to open up a passage for urine to flow.

  • Use of a stent. There are two types of prostatic stent — temporary and permanent. Permanent stents are essentially tubes inserted to widen the passage through the urethra and that induce epithelization (becomes covered with epithelial cells, the type of cells that normally coat many surfaces and linings in the body) over 6-12 months, and are not intended to be removed. Temporary stents, such as certain plastic stents that are intended to be removed (which are not dissimilar to a foley catheter but they reside completely in the urethra), or stents that biodegrade over 2-12 months.

3.) Treatments that remove or reduce prostate tissue include:

  • Certain medications; for example, 5-alpha reductase inhibitors to try to shrink the prostate.

  • Certain minimally invasive surgical approaches. One would be ablation procedures (which are performed with specialized instruments inserted into the urethra under local and/or general anesthesia), where energy is used to destroy some of the prostate tissue. There are also techniques to "starve" some of the prostate tissue such as embolizing an artery to diminish its blood supply.

  • More invasive surgical approaches to "cut out" some prostate tissue, whether using an open technique or a transurethral approach (transurethral resection of the prostate, often called a TURP), and whether done laparoscopically, robotic assisted or another way. The more invasive approaches are typically used in patients where the less invasive approaches above are either not an option (such as in patients with frequent infections, recurrent large amounts of blood in their urine, urine retention severe enough to compromise kidney function, others) or were ineffective.

Because there are so many treatments for benign prostatic hyperplasia, it's important that patients speak with their urologists to discuss the pros and cons of each. Informed decisions can then be made as to what treatment option to try, knowing that if it is not effective, or loses efficacy over time, that another treatment is possible.

Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com

This article originally appeared on MetroWest Daily News: Dr. Jeff Hersh addresses enlarged prostates not caused by cancer