Benign prostate enlargement: When is treatment required?

In this informative guide to benign prostate enlargement, highly respected consultant urological surgeon Mr Nimalan Arumainayagam shares his expert insight on the most common symptoms of the condition and explains the possible complications of the most serious cases. In addition, the leading specialist outlines the various approaches to treatment available for benign prostate enlargement.

What is benign prostate enlargement?

Benign prostate enlargement, or benign prostate hyperplasia (BPH), is very common and affects fifty per cent of men over the age of fifty. Essentially BPH is the enlargement of the prostate over time due to hypertrophy of the cells. This causes impingement on the urethra and the bladder outlet, which can result in difficulty passing urine, a poor flow and a sensation of not emptying the bladder completely.

If the bladder doesn't empty completely, this can result in urinary frequency because the bladder fills up very quickly again. These are the most common symptoms associated with benign prostatic enlargement. BPH isn't cancerous but often does need treatment with either medication, fluid management or surgical intervention in some cases.

How common is benign prostatic enlargement?

Benign prostatic enlargement is a common condition which affects fifty percent of men over the age of fifty and becomes more common as men get older.

There is possibly tenuous family history or a familial predisposition in some men, but we don't fully understand that at present. BPH is more common in some ethnic groups in terms of the prostate being more enlarged, specifically in Afro-Caribbean men who can potentially be more at risk. However, it can affect all men and that's the important thing to note.

As a urologist, this is our bread and butter - we see a lot of men with benign prostatic enlargement, and we are able to offer a variety of treatments to improve patients’ symptoms and quality of life.

Is benign prostate enlargement serious?

Benign prostatic enlargement in itself can cause serious consequences. If the prostate is enlarged to a degree that the bladder isn't able to empty properly, that can predispose men to urinary tract infections.

BPH can, in its most severe form, cause acute urinary retention, whereby the man can't pass urine at all and then needs emergency intervention to insert a urethral catheter to drain the bladder. It can also cause back pressure on the kidneys if the bladder is completely full and is not emptying at all. This, in turn, can actually cause the kidneys not to work and may lead to damage to the kidneys in the long-term if left untreated for a prolonged period of time.

There isn't a direct associated cancer risk with benign prostatic enlargement. However, men with BPH can also develop cancer because everyone has a lifetime risk of one in eight or one in four if the individual has a family history of prostate cancer.

BPH and cancer are very different entities and if a man is diagnosed with benign prostate enlargement, it doesn't necessarily mean that he's at increased risk of developing prostate cancer, rather he will still have the same baseline risk that he's always had.

When is treatment required? What are the most popular treatment options?

Treatment is often required when symptoms are problematic. We use a variety of tools to gauge how severe a patient’s symptoms are, including questionnaires which also allow us to determine a quality of life score.

The best treatment is obviously the least invasive. In my opinion, this requires fluid management, a bit of lifestyle modification and sometimes medication to relax the prostate. We use alpha blockers, which are drugs that essentially allow the prostate and the bladder neck to relax and help the bladder empty better.

There are also other drugs which reduce the size of the prostate but these take many months to work. We can sometimes use these medications in combination because they work in different ways and that often results in a good functional outcome and also avoids the need for surgical intervention.

If those treatments are ineffective or the patient’s symptoms are severe, surgical intervention is often the preferred route, especially in men who have a high degree of urinary retention or who have gone to complete urinary retention and cannot get catheter-free.

There are lots of options available to men now, including minimally invasive surgical approaches, such as prostate artery embolisation, intraprostatic steam injection using Rezūm (a new modality used to reduce the size of the prostate), and UroLift, which involves the insertion of implants to open up the prostate and help the bladder empty.

There are also surgical options including transurethral resection of the prostate (TURP), a very good technique which has been around for many years and also involves opening up the prostate. In addition, there is GreenLight laser vaporisation of the prostate and Holmium laser enucleation of the prostate (HoLEP).

Amongst the many options available, some are better suited to some men than others so this really requires a discussion with a specialist to determine which is the right approach. An assessment of the prostate anatomy and size helps to inform this decision on the best way forward for each patient.

How has the treatment of benign prostate enlargement developed in recent years?

Traditionally, the gold standard treatment of BPH was a transurethral resection of the prostate (TURP). This is still a very good treatment and we continue to offer this for lots of men. It allows us to collect tissue to make sure that there isn't any incidental cancer, which is sometimes picked up.

Essentially, this is still what we would call the gold standard, but there are lots of new treatments which are very good but have less history. Therefore, we don't have any long-term follow-up for some of these treatments, such as UroLift, Rezūm or prostate artery embolisation. Nonetheless, these more innovative treatments have good, immediate (five-year) outcomes.

All approaches to treatment have their advantages and limitations. Prostate artery embolisation is performed under local anaesthetic as a day-case procedure, meaning general anaesthesia is avoided. Rezum, Urolift and green light laser vaporisation procedures may be performed as a day-case procedure or may require just one overnight stay in hospital, as with TURP or HoLEP procedures. Although the approaches may differ, these forms of treatment have resulted in good functional outcomes for many of my patients.

If you are concerned about benign prostate enlargement and wish to schedule a consultation with Mr Arumainayagam, you can do so by visiting his Top Doctors profile.