Mount Sinai has extensive experience in treating benign prostatic hyperplasia (BPH). Once we diagnose this condition, we determine the most appropriate treatment, depending on how severe your symptoms are.
Treatment options for lower urinary track symptoms (LUTS) include watchful waiting and progress through medical to surgical interventions. For the majority of patients their starting point on the treatment pathway will be dictated by their symptoms and degree of discomfort.
If you are experiencing mild symptoms (IPSS ≤7) or moderate symptoms with minimal discomfort, your condition can be managed with watchful waiting. Watchful waiting includes recommendations for lifestyle changes that can help ease or circumvent symptoms. These changes include advice about the volume and timing of fluid consumption, avoidance of caffeine, abstinence of evening alcohol and regulation of bowels. Over-the-counter ‘decongestants’ should also be avoided as they can exacerbate symptoms.
The aim of medical therapy is to improve your symptoms, lower the risk of progression and improve your quality of life. There are many pharmaceutical options with guidelines and algorithms readily available to help guide your selection.
- Alpha blockers, such as Flomax®, (tamsulosin) Cardura® (Doxazosin), and Hytrin® (Terazosin), work on the bladder neck (bladder opening) and prostatic urethra (area of the urethra surrounded by the prostate). By blocking the receptors that that cause these channels to compress and close, the medications help the bladder neck and prostatic urethra to dilate and open, which improves urine flow. You will probably find that your symptoms improve after you’ve been taking the medication for a few days. This approach is most effective for people with mild to moderate symptoms.
- 5 Alpha reductase inhibitors, such as Proscar®, block your 5 alpha reductase enzyme, which stops production of dihydrotestosterone (DHT) in your prostate and slows or stops the growth of the prostate. We often use these medications together with alpha blockers. It may take three to six months before you feel any improvement. This approach is best for prostates that are significantly enlarged. Please note that these medications will also decrease your prostate specific antigen (PSA) by 50 percent, so if you are taking this medication and a doctor is monitoring your PSA, you should alert your doctor that you are taking an alpha reductase inhibitor so that we can appropriately assess your levels.
- Phosphodiesterase 5 inhibitors, such as Cialis (tadalfil) uses another pathway to reduce smooth muscle contractility. Inhibition of phosphodiesterase type 5 (PDE5) allows relaxation of smooth muscle in the bladder neck, urethra and prostate. The most effect dosing appears to be 5mg tadalafil daily, which improves erections as well as LUTS.
- Antimuscarinics are designed to reduce bladder irritability which may cause urgency and frequency. In men bothered mainly by irritable symptoms, the use of anti-cholinergic medication can provide better symptom relief. Agents include anti-muscarinics (non-selective: oxybutynin, tolterodine and selective: solifenacin) and β 3-adrenoceptor agonists (mirabegon).
Combining agents from different pathways can have a synergistic effect. The most common combination is dutasteride with tamsulosin. This combination has been shown to not only produce durable improvement in voiding symptoms but significantly reduces the risk of disease progression, and in particular, decreases the risk of retention.
The combination of tamsulosin with tadalafil has also been investigated.
There are many surgical options available to you that can be classified into three main groups: Compressing the prostate tissue, removing some of the prostate enlargement, or removal of the entire enlargement.
UroLift: Involves the insertion of a device which compresses the prostate laterally thus widens the urethral channel. This approach is relatively new and usually reserved for men with mild to moderate symptoms or in men who are not fit for a more definitive procedure. This procedure can be done in our office. The Urolift leads to short-medium term improvements in symptoms and emptying of the urinary bladder. In addition, there may be improvement in sexual function and avoidance of retrograde ejaculation, a common side effect from other operative interventions.
ReZum: This is also known as convective radiofrequency water vapor thermal therapy, which is a minimally invasive procedure that can be performed in our outpatient facility. We use a hand-held device that passes through the urethra to reach the prostate. The energy transported by the water damages the offensive cells, which in turn causes them to die. Over time, the body absorbs the treated tissue as part of the natural healing process, and as it does, your symptoms of BPH are relieved. We have had very good results using Rezum with improvements in symptoms, as well as preservation of ejaculation.
Surgical treatments for BPH vary widely. Here are the most common procedures.
Transurethral resection of the prostate is the ‘gold standard’ against which we compare all other surgical prostate treatments, because it has historically had the best results. This hospital-based procedure, performed under anesthesia, involves scraping (resecting) prostate tissue within the urethra to create an open channel to urinate through. Afterward, we perform continuous bladder irrigation to remove any blood and clots that may form after the procedure. We usually do a ‘voiding trial’ (removing the catheter to see if you can urinate) a day or two after the procedure.
Bi-polar diathermy has the advantage of allowing resection with saline irrigation. Greenlight laser vaporisation, which also utilizes saline irrigation, has the additional advantages of being able to be performed while patients remain on anticoagulation therapy and as a 1-day procedure. Microwave treatment can also be done as a day procedure with minimal risk.