How is benign prostatic hyperplasia (BPH) treated?
There are a number of treatment options depending on the degree of discomfort and bother associated with BPH, lifestyle factors, and complications from the enlarged prostate or the blockage of urine. Treatment options include the following: no treatment or watchful waiting, drugs, and/or surgery.
Read below for information about each treatment:
No Treatment or Watchful Waiting
For those with mild cases of BPH, where symptoms are tolerable, treatment may not be necessary. In these cases the patient must still be monitored to ensure their problem does not worsen. Monitoring involves keeping an eye on the BPH symptoms, the size of the prostate, and regular blood tests. Limiting fluids in the evening, avoiding caffeinated drinks, alcohol, and spicy foods may minimize symptoms.
Men with mild to moderate symptoms may try over-the-counter herbal/plant therapy (e.g. Serenoa repens, Saw Palmetto, and Pygeum Africanum). It should be noted that manufacturers have found it difficult to ensure potency and product-to-product consistency, given the nature of herbal/plant therapies.
There are two types of prescription medications available to treat BPH symptoms: alpha-blockers and 5-alpha reductase inhibitors.
Alpha blockers relax the muscles in the prostate gland and the bladder opening, which is like “taking the clamp off of a hose”. If this treatment option works, symptoms associated with BPH usually improve within one to two weeks. The drugs currently available include doxazosin, terazosin, tamsulosin, silodosin, and alfuzosin.
Side effects associated with alpha blocker treatment may include the following:
- dizziness, tiredness, or decreased blood pressure
- retrograde ejaculation, where semen passes back into the bladder during orgasm instead of being ejected externally
- nasal stuffiness
All these side effects are usually reversible when the medication is stopped. Care must be taken in men being treated for high blood pressure as some alpha blockers might interact with erection drugs. Also, if you are going to have cataract surgery, be sure to inform your eye surgeon that you are on these medications as it could impact on the surgery (“floppy iris syndrome”).
5-alpha reductase inhibitors are a “mild form” of hormone treatment that reduces the size of the prostate gland by blocking a male hormone from stimulating prostate growth. It may take three to six months for symptoms associated with BPH to improve while taking this type of medication. This drug is most useful in men with larger prostates.
Approximately three percent of patients experience reduced sex drive, poor erections, or decreased volume of semen as a side effect of this treatment. Small numbers of men may notice breast tenderness and enlargement.
Combination therapy involves the use of both an alpha blocker and a 5-alpha reductase inhibitor. Two studies have confirmed that in men with larger prostates this approach appeared to be effective in relieving and preventing symptoms and reduced the long-term need for BPH-related surgery.
Surgery is typically used in men with moderate to severe symptoms, when drug treatment fails, or those with complications such as frequent infections, bleeding, or episodes of retention. There are several minor therapies that may be effective to a degree and have few complications and a short healing time. These are mostly heat based treatments, which include microwave thermotherapy, radiofrequency needle waves, laser coagulation, water-induced thermal therapy, and high intensity ultrasound. More invasive surgery for BPH involves cut(s) through, or removal of part of the prostate gland, either through the urethra (Transurethral Resection) or, less commonly, through an open operation via the abdomen (Retropubic prostatectomy).
Transurethral Resection of the Prostate (TURP) is considered by many urologists to be the gold standard procedure. TURP involves removal of the inner portion of the prostate in small pieces, perhaps like removing the core of an apple. It is done by using a small camera that is guided through the urethra in the penis, therefore avoiding any external cuts into the abdomen. The tissue may be removed using electrocautery or vaporized with an electrode or with laser energy.
Retropubic Prostatectomy involves the removal of most of the inner prostate via a cut in the abdomen. It is required for very large prostate glands. Modern laser techniques are being used successfully for large prostates, which avoids the need for an abdominal scar. Several centres are also using the daVinci robot to remove BPH.
The side effects of surgery may include frequent urination, blood in the urine, difficulty achieving an erection, urinary leakage, or narrowing (scarring) in the urethral channel. Approximately 75% of men will experience retrograde ejaculation following a TURP. Some men require a repeat of this procedure several years later as the benign growth can reform.