Problems with the prostate are common in older men, and, while not all prostate issues involve cancer, they need the expertise of a top urologist. We talked to such a specialist, Mr Neil Barber, who answered our questions: what is BPH? And how do you treat it?
What is BPH (benign prostatic hyperplasia)?
Benign growth of the prostate, often known as BPH (benign prostatic hypertrophy/hyperplasia), is an almost ubiquitous feature of the ageing male. Most men from middle age will start to suffer some increase in size of the prostate.
For some men, that growth will start to cause urinary symptoms, including a progressive obstruction to the flow of urine out of the bladder. Those symptoms can include those relating to the flow:
- A slow stream of urine
- Hesitancy initiating that stream
- A sensation of poor bladder emptying
Those symptoms relating to the storage of urine in the bladder, which can often cause the most bother:
- Getting up at night to pass urine, leading to sleeplessness and mood irritation.
- Urgency; that is, being unable to hold on and having to rush to the loo, or even leakage before getting there.
- Frequency – needing to go to the loo very frequently during the day.
These symptoms can affect up to 60% of men aged 60, although only a minority ever seek help in terms of receiving treatment, and only a subsection of that go on to have surgical intervention.
What are the options for BPH treatment?
When advising a man regarding his bothersome waterworks symptoms that are thought to relate to the benign growth of his prostate and obstruction to the flow of urine out of the bladder, initially, we look to employ conservative measures – essentially fluid management. Reducing caffeine intake and alcohol intake can help with the very bothersome symptoms that relate to the storage of urine; that is, frequency, urgency and getting up at night to pass urine.
We can also employ approaches such as pelvic floor exercises and bladder training techniques.
Beyond that, if these conservative measures don't help, then we start to look at the option of medical therapy, usually in the first instance. The classic first tablet to try would be an alpha blocker, usually tamsulosin, which looks to relax the smooth muscle within the prostate and then the neck of the bladder to decease obstruction to a degree and hopefully improve symptoms. These tablets are well-tolerated with minimal side-effects and, if effective, are taken in the longer term. Further tablets taken to shrink the prostate can be added to this, or indeed used as monotherapy, examples being finasteride and dutasteride.
If the tablets don't work, aren’t tolerated, or worked for a while and then the symptoms returned over time, then the next step in treatment is surgical intervention.
The more invasive interventions, on the whole, look to remove tissue to ‘core out’ the prostate, if you like, to maximise the likely improvement of symptoms, both in terms of the flow of urine and those related to storage.
Less invasive options look to improve symptoms but lessen side effects and promote a quicker recovery.
What are the potential side-effects of medication and prostate surgery?
On the whole, medication is well-tolerated. The alpha blockers may have side-effects, including those relating to headache, blocked nose and dizziness, and some men can also describe developing dry ejaculation. Finasteride or dutasteride, the 5-alpha reductase inhibitors can have a deleterious effect on sexual function in terms of libido and loss of erectile function.
What are the surgical options?
In terms of surgical interventions, the standard, more invasive surgery where you remove tissue, such as TURP, holmium laser enucleation of the prostate or GreenLight™ Laser will improve your symptoms reliably, but also represents somewhere between a 40-70% chance of leaving you with permanent dry ejaculation, and a small figure of probably less than 5% of affecting erectile function.
The less invasive approaches such as the prostatic urethral lift procedure using UroLift® implants, whilst it’s less effective in terms of the level of symptom improvement, have essentially a zero percent chance of affecting your sexual function.
Other, newer, less invasive approaches such as Rezūm have about a 10% risk of giving you permanent dry ejaculation, and an even newer device called iTind has similar figures.