Your Treatment Options for an Enlarged Prostate
Research shows that 83% of men consider enlarged prostate symptoms, like straining to urinate or having a weak flow, to be normal signs of aging—which may help explain why just 13% are willing to discuss their symptoms. Yet misinformation and reticence are only part of the problem: Another recent survey found that 30% of men with an enlarged prostate, a.k.a., benign prostatic hyperplasia (BPH), aren’t getting treatment because they don’t like their treatment options. But there are many great treatments available. We’ll outline them here.
Symptoms of an Enlarged Prostate
The prostate is a small gland situated between the penis and the bladder, which makes fluid for semen. When it becomes enlarged, it puts pressure on the bladder and the urethra, affecting how frequently you need to pee, and makes starting to urinate difficult, as well as fully emptying the bladder. While it’s usually not a serious health threat (you’re not at an increased risk of prostate cancer), symptoms shouldn’t be ignored. BPH can lead to urinary tract infection (UTI) and/or acute urinary retention (the sudden inability to pass urine, causing stomach pain and a swollen bladder). Untreated, BPH can lead to bladder and kidney damage.
Why Does This Happen?
Experts don’t entirely know what causes an enlarged prostate, but it’s likely tied to hormones. According to the Urology Care Foundation, as men age, testosterone levels naturally lower, making estrogen a more prominent hormone than in the past. It’s thought that higher estrogen may be involved in causing prostate cells to grow. Another theory: When testosterone declines, another male hormone tied to prostate development, called dihydrotestosterone (DHT), builds. Either way, aging and a family history of BPH ups your odds. So does obesity, lack of physical activity, and erectile dysfunction.
Sexual Issues and BPH
Research shows that 70% of men with BPH also have erectile dysfunction (ED). That doesn’t mean that enlarged prostate causes ED, or vice versa. It simply means there’s an association, per a report in the journal European Urology Focus. The clearer connection is that certain BPH treatments impact sexual function. For example, certain BPH meds may cause trouble with ejaculation, reduced libido, or ED. And surgical procedures may cause ejaculatory dysfunction and/or worsen existing ED. Sexual side effects from surgical treatments are more likely to be permanent than those from other treatments.
Treatment Is Not Always Needed
Men with BPH are treated with drugs, minimally invasive therapies, and/or surgery. Your age, health, size of your prostate, and how much discomfort you’re experiencing all factor into which treatments you’re given. If your symptoms don't bother you, your doc may simply monitor the situation. “This is reasonable when the severity of the condition doesn’t pose any major threats to you,” says Brad Gill, M.D., a urologist at the Cleveland Clinic’s Glickman Urological & Kidney Institute in Ohio. Avoiding alcohol, caffeine, decongestants, and antihistamines; exercising regularly; and avoiding fluids within two hours of bedtime may help.
High Blood Pressure Meds May Help
“Alpha blockers, which relax the muscles of the prostate and bladder, are a good starting point for BPH,” says Dr. Gill. Cardura (doxazosin), Flomax (tamsulosin), Rapaflo (silodosin), and Uroxatral (uzosin) are most often used to help relieve symptoms caused by smaller to moderately enlarged prostates. However, “some specific shapes of prostates, or very enlarged prostates, may not respond well to medications,” says Dr. Gill. “These usually aren’t ideal for those [who are] on multiple blood pressure medications, since alpha blockers further lower blood pressure.” Side effects may include dizziness, fatigue and trouble ejaculating.
Hormone Blockers for Shrinkage
Hormone blockers, or 5-alpha reductase inhibitors (5-ARI), either alone or along with alpha blockers, is another mainstay BPH treatment. “This option is best for men with larger prostates,” says Robert Siemens, M.D., deputy chair of the department of urology at Queen’s University School of Medicine in Ontario. These meds shrink the prostate by preventing hormonal changes that cause the prostate to grow. Drugs like Avodart (dutasteride) and Proscar (finasteride) can take up to six months to achieve maximum shrinkage. Side effects may include ED, reduced libido, and retrograde ejaculation (when semen enters the bladder).
Alpha Blockers and Heart Health
A 2021 report in The Journal of Urology found that men taking alpha blockers were at a 22% higher risk of cardiac failure. (That jumped to 16% higher on a combination of alpha blocker and 5-ARI, with risk up 9% among men on 5-ARI alone.) While this sounds scary, Dr. Siemens, who conducted the research, notes that no one should stop taking BPH medications based on the study’s results alone. “Our research highlights that urologists and primary care physicians should think about the cardiovascular health of their patients with an enlarged prostate—and take it into consideration when evaluating and managing symptoms."
ED Meds for Better Urine Flow
ED medications, known as phosphodiesterase 5 inhibitors, can be used in place of, and sometimes in combo with, other BPH medications. “These medications relax some of the smooth muscle in the prostate—and possibly the bladder—helping the urine flow through it more freely,” explains Dr. Gill. For men who are experiencing BPH and ED, daily Cialis (tadalafil) may help both conditions. As with other BPH drugs, it’s smart to get your heart health checked first. “PDE5 inhibitors should never be used in anyone taking nitrates for blood pressure control or nitroglycerin for chest pain,” adds Dr. Gill.
Procedures for Enlarged Prostate
“Over the past five years the number of interventions to treat BPH have grown. Now, there are many excellent alternatives to medicines and can be considered alongside them as treatment options,” says Dr. Gill. “This is particularly helpful for patients who prefer not to take daily medications.” The best procedure for BPH management is determined by your preferences, prostate size and configuration, and your urologist’s expertise, he adds. “Some of the newer in-office and operating rooms procedures can treat BPH while maintaining ejaculation, which traditionally was something that was sacrificed with any BPH procedure.”
Procedures for Erectile Function
Water vapor therapy is a minimally invasive therapy that delivers water vapor directly to the prostate, destroying tissue. Painless and performed under general anesthesia, it takes three months of repeated visits to complete, and ejaculatory and erectile functions are often preserved. A prostatic urethral lift uses implants to move tissue to improve urine flow. Performed under general anesthesia, it also preserves ejaculatory and erectile function, says Seth Bechis, M.D., assistant professor of urology at UC San Diego. Some men may eventually need to restart medication or have another procedure down the line, he adds.
Therapies for Better Urine Flow
Many minimally invasive therapies rely on heat to destroy prostatic tissue, including laser surgery to zap prostate tissue, allowing for a better urine flow. This requires general anesthesia and a catheter for one or more days. Transurethral microwave therapy (TUMT) uses microwave energy to kill tissue inside the prostate, while a thermometer is inserted into the rectum to check temperature during the procedure. “This partially relieves symptoms,” says Dr. Bechis. TUMT is generally reserved for those with small prostates in special circumstances since re-treatment might be necessary.
Invasive Surgery an Option, Too
According to the American Urological Association, invasive surgical treatments are appropriate for men with moderate-to-severe lower urinary tract symptoms, acute urinary retention, and/or other complications related to BPH. The most common surgery is transurethral resection of the prostate (TURP), which is considered “the gold standard against which other procedures are compared,” notes Dr. Bechis. For this procedure, a lighted scope is inserted into the urethra to remove tissue that’s blocking urine flow. The average hospital stay is one to two days. (Erectile function and continence are usually retained.)
Additional Treatments for BPH
But that’s not all. “The entire prostate is removed through a transurethral procedure” known as holmium laser enucleation of the prostate (HoLEP), notes Dr. Bechis—generally with excellent outcomes, he adds. For a transurethral incision of the prostate (TUIP), the bladder neck and prostate are cut to relax the bladder opening, enabling urine to flow easily. (TUIP is most successful on men with smaller prostates.) Finally, for very enlarged prostates (and when there is damage to the bladder), an incision is made to remove either all or part of the prostate in a procedure called prostatectomy. General anesthesia is needed.
Improved Symptoms After Treatment
By and large, BPH symptoms improve after treatment, with varying side effects (depending on the type of treatment you choose). Good news: Most healthcare providers agree that if you were able to maintain an erection before surgery for your enlarged prostate, you’ll likely be able to have erections post-op, too. Looking forward, it’s important to know that about 10% of men treated with TURP or TUIP require additional surgery within five years. And roughly 2% of men who have an open prostatectomy require additional surgery within that same time span.